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Oklahoma State Department of Health
2011 Infection Prevention and Control Manual
Infection Prevention and Control Manual Committee Members
Susan Boyd, MS, RN
Kristy Bradley, DVM, MPH
Becky Coffman, MPH, RN, CIC
Sarah Flora, BSN, RN
Ginger James, BSN, RN, Chairperson
Phillip Lindsey, MD
Alan B. Loch, EC
Rocky McElvany, OSDH Safety Officer
Diana Pistole, MPH, MSN, ARNP
Debbie Purton, MPH, RN
Jana Winfree, DDS
RECORD OF CHANGES
OSDH INFECTION PREVENTION AND CONTROL MANUAL
(This plan is reviewed and updated annually)
Section
Date
MODIFIED: Section 1 Occupational Health Program-
Tuberculosis (TB) Skin Testing P. 1-4
Illness and Injury Reporting P. 8
January 2009
MODIFIED: Section 2 Management of Occupational Exposure to Bloodborne Pathogens-
Reporting an Exposure P. 12
January 2009
MODIFIED: Section 3 Infection Prevention Practices P. 19 - 30
NEW: Foot ware P.22
NEW: Respiratory Hygiene P. 23
NEW: Safe Injection Practices P. 23
January 2009
MODIFIED: Section 4 Guidelines for Cleaning, Disinfection and Sterilizing
New: Product Sterility and Shelf-life
P. 31
January 2009
MODIFIED: Section 6 TB Control Masks P. 51
Respiratory Isolation Room P. 51-52
January 2009
MODIFIED: Section 7 Infection Prevention and Control Guidelines for Clients Presenting with Rash Illnesses
P. 55
January 2009
UPDATED: Appendix 1A, 1C, 2K;
6A-F re-numbered to 5A-F
January 2009
UPDATED: Bibliography P. 125-127
January 2009
MODIFIED: Section 1, P. 2
Section 1, P. 6 & 7
January 2010
MODIFIED: Section 2, P. 17, HCV Testing
January 2010
UPDATED: Section 3 Infection Prevention
January 2010
MODIFIED: Section 6
January 2010
MODIFIED: Section 7
January 2010
MODIFIED: Appendix 1-D
January 2010
UPDATED: Infection Control Committee Members
January 2011
UPDATED: Section 1, P.1
January 2011 OSDH INFECTION PREVENTION AND CONTROL MANUAL
(This plan is reviewed and updated annually)
Section
Date
MODIFIED: Section 3, Standard Precautions: b, d, h, i
January 2011
UPDATED: Section 3, Transmission Based Precautions
January 2011
UPDATED: Section 3, Bioterrorism Agents
January 2011
MODIFIED: Section 4, Laboratory Equipment, Autoclaves
January 2011
MODIFIED: Section 4, Dental Instruments and Equipment
January 2011
UPDATED: Section 6
January 2011
UPDATED: Section 7
January 2011
UPDATED: Appendix 1-C, 1-F, 3-A, 5-C, 5-F
January 2011
UPDATED: Bibliography
January 2011
2011 Infection Prevention & Control Manual i
Table of Contents
Section 1: Occupational Health Program
Screening ......................................................................................................................... 1
Immunizations ................................................................................................................. 4
Immunocompromised Employees ................................................................................... 6
Health Education and Counseling ................................................................................. 6
Occupational Illness and Injury Reporting .................................................................... 7
Contract Agencies/Employees ......................................................................................... 8
Protection from Bloodborne Pathogens ......................................................................... 9
Employee Medical Records ............................................................................................. 9
Section 2: Management of Occupational Exposure to Bloodborne Pathogens
Treatment of Exposure Site ......................................................................................... 11
Reporting an Exposure ................................................................................................ 12
Testing ......................................................................................................................... 13
Exposure Evaluation for Counseling ........................................................................... 15
Source Client Evaluation ............................................................................................. 15
Management and Follow-up of Potential Exposure to HBV ....................................... 16
Management and Follow-up of Potential Exposure to HCV ....................................... 17
Management and Follow-up of Potential Exposure to HIV ........................................ 17
Section 3: Infection Prevention Practices
Standard Precautions ................................................................................................... 19
Transmission Based Precautions ................................................................................. 24
Infection Prevention and Control for Potential Bioterrorism Agents .......................... 25
Guidelines for the Work Setting .................................................................................. 27
Section 4:Guidelines for Cleaning, Disinfecting and Sterilizing
Product Sterility and Shelf-life .................................................................................... 31
Disinfectant Solutions.................................................................................................. 32
General Area Maintenance .......................................................................................... 32
Medical Equipment...................................................................................................... 34
Laboratory Equipment ................................................................................................. 35
Dental Instruments and Equipment ............................................................................. 38
Emergency Medical Equipment .................................................................................. 40
Section 5: Management of Regulated Medical Waste
Regulated Medical Waste Disposal Plan ..................................................................... 43
Definitions ................................................................................................................... 43
Examples of Regulated Medical Waste Within a County Health Department ............ 44
Disposal of Regulated Medical Waste......................................................................... 45
2011 Infection Prevention and Control Manual ii
Section 5: Management of Regulated Medical Waste
Storage of Regulated Medical Waste in a County Health Department Prior to Final Disposal ....................................................................................................................... 46
Options for Final Disposal of Regulated Medical Waste ............................................ 46
Transportation of Untreated Regulated Medical Waste by County Health Department Personnel .................................................................................................. 46
Section 6: Guidelines for the Prevention of Respiratory Transmitted Diseases in the Clinic Setting
Management of Client Waiting Areas .......................................................................... 49
Prevention of Tuberculosis Infection ........................................................................... 50
Tuberculosis Control Masks ........................................................................................ 50
Respiratory Isolation Room ......................................................................................... 51
Ultraviolet Irradiation .................................................................................................. 53
Sputum Specimen Collection ...................................................................................... 53
Written Tuberculosis Control Plan .............................................................................. 54
Pandemic Influenza ...................................................................................................... 54
Section 7: Infection Prevention and Control Guidelines for Clients Presenting with Rash Illnesses
Terminology ................................................................................................................ 56
Triage ........................................................................................................................... 56
Methods of Transmission .............................................................................................. 57
Management of Client Waiting Areas
Standard Precautions: Respiratory Hygiene/Cough Etiquette .................................... 57
Expanded Precautions: Droplet and Airborne ............................................................ 58
APPENDICES
Appendix 1-A - Tuberculosis Control Program ........................................................... 61
TB Mask Issuance Record ........................................................................................... 63
Appendix 1-B ................................................................................................................. 65
Annual Mask Fit Evaluation Form
Appendix 1-C ................................................................................................................. 67
Employees at Risk
Appendix 1-D ................................................................................................................. 69
Employee Training Record
Appendix 1-E ................................................................................................................. 71
Engineered Safety Devices Recommended Memo
Appendix 1-F ................................................................................................................. 73
Sequence For Donning Personal Protective Equipment
Appendix 2-A ................................................................................................................. 75
Post-Exposure Counseling Check Sheet, OSDH
2011 Infection Prevention and Control Manual iii
Appendix 2-B ................................................................................................................. 77
Occupational Exposure Report Form
Appendix 2-C ................................................................................................................. 81
Source Client Information
Appendix 2-D ................................................................................................................. 83
HIV/HBV Risk Factor Assessment: Population Groups and Risk Categories
Appendix 2-E ................................................................................................................. 85
Recommended Postexposure Prophylaxis Hepatitis B Virus
Appendix 2-F ................................................................................................................. 87
Information For Health Care Providers: Exposure To HbsAg Positive Or High Risk Client
Appendix 2-G ................................................................................................................. 89
HIV Postexposure Prophylaxis for Percutaneous Injuries
Appendix 2-H ................................................................................................................. 91
HIV Postexposure Prophylaxis for Mucous Membrane Exposures and Nonintact Skin Exposures
Appendix 2-I .................................................................................................................. 93
Referral Policy: Postexposure Prophylaxis Following Occupational Risk Exposures To HIV
Appendix 2-J .................................................................................................................. 95
Information For Health Care Providers: Exposure To HIV Positive Or High Risk Client
Appendix 2-K ................................................................................................................. 97
Exposure Flow Chart
Appendix 3-A ................................................................................................................. 99
Type and Duration of Precautions Needed for Selected Infections and Conditions
Appendix 3-B ............................................................................................................... 105
Respiratory Hygiene/Cough Etiquette
Appendix 4-A ............................................................................................................... 107
Sample Autoclave Monitoring Log
Appendix 5-A ............................................................................................................... 109
Isolation Room View
Appendix 5-B ............................................................................................................... 111
County Health Department Respiratory Isolation Room Inspection Report
Appendix 5-C ............................................................................................................... 113
Minimum Requirements for Tuberculosis Control
Appendix 5-D ............................................................................................................... 115
County Health Department Written TB Control Plan
2011 Infection Prevention and Control Manual iv
Appendix 5-E ............................................................................................................... 119
Negative Pressure Isolation Room Test Log
Appendix 5-F ............................................................................................................... 121
Infection Prevention Recommendations for Care of Patients With Pandemic Influenza
Bibliography .................................................................................................................. 123
Glossary Terms ............................................................................................................. 127
2011 Infection Prevention & Control Manual 1
Occupational Health Program
ealth care workers who provide direct services to or who work in the vicinity of persons who may be ill, are at increased risk for acquiring and transmitting infectious diseases. Direct service involves working face to face with clients or having ―hands on‖ contact with clients. Additionally, there are a number of infectious processes that present a possible threat to a health care worker that are vaccine preventable, or have specific indications for post exposure prophylaxis. Because the health and safety of Oklahoma State Department of Health (OSDH) employees is of utmost concern for the agency, an active Occupational Health Program is in place. The Occupational Health Program has two important goals:
To protect clients and employees by Facilitating disease detection and treatment Eliminating or minimizing occupational exposure to bloodborne pathogens Managing exposures to communicable disease Promoting a safe environment Promoting employee education
To comply with government regulations Occupational Safety and Health Administration (OSHA) Oklahoma Department of Labor (ODOL) Oklahoma Public Health Code
Infection control and safety are both important parts of any Occupational Health Program. Infection control standards serve to provide a safer environment to employees by facilitating prevention, detection and control of communicable diseases within the work setting.
Screening
Tuberculosis (TB)
Employee screening for M. tuberculosis infection status will follow the MMWR December 30, 2005 Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005.
Section
1
H 2011 Infection Prevention and Control Manual 2
1. Baseline evaluation for M. tuberculosis infection- Documentation of baseline M. tuberculosis infection status is required for all new employees and directly observed therapy (DOT) providers at county health departments and for all new central office staff with direct client contact. Baseline evaluation requires either 1) tuberculin skin testing using the Mantoux method or, 2) specific documentation of having a prior positive tuberculin skin test (with date applied and measurement in millimeters of induration). Specific recommendations for baseline evaluation are as follows:
Perform ―two-step‖ baseline testing on individuals with:
a) no previous TST result
b) single previous negative TST result (documented or not) >12 months before new employment
c) previous undocumented positive TST result
d) history of BCG vaccination
Perform single TST baseline testing on individuals with:
a) two or more documented negative TSTs (but most recent TST
>12 months before new employment)
b) single previous documented negative TST result ≤ 12 months
before new employment)
Note: Both the single-step and the two-step TST are to be performed in accordance with the MMWR December 30, 2005 Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005.
Do not perform baseline or subsequent TST on individuals with:
a) previous documented positive TST result
b) documented completion of treatment for latent TB infection or TB disease
c) documented ulceronecrotic reaction to a prior TST or documented true anaphylactic reaction to prior TST
Note: in individuals a, b or c (immediately above) a symptom screen is all that is required for baseline or subsequent TB screening.
2. Follow-up (serial) evaluation for M. tuberculosis infection- Tuberculin skin testing must be performed annually for all county health department employees, DOT providers and for all central office employees with direct client contact, unless a previous positive tuberculin skin test has been documented or a contraindication to TST exists. Employees who consistently work with active TB cases should be tested every 6 months. A single-step TST is all that is ever required. Two-step testing SHOULD NOT be performed for follow-up testing. If an employee develops symptoms suggestive of tuberculosis, they should be referred to their county health department for evaluation.
3. Follow-up for an Employee or DOT Provider with a Positive TST- An employee with an initially positive TST should be referred to a private physician or the county health department for a chest x-ray and medical evaluation. An Incident Report ODH Form 33 should be completed and forwarded to the Safety Officer. The ODH Form 33 can be accessed through Public Folders under Administrative Policy 6-24 or through the Safety 2011 Infection Prevention and Control Manual 3
Program. The employee should be educated regarding the signs and symptoms of TB, and instructed to notify his/her supervisor if symptoms suspicious of TB occur. An evaluation should then be performed to rule out active TB.
An employee with a history of a positive tuberculin skin test (TST) and a negative chest x-ray (whether they have taken preventive therapy or not) should not have additional chest x-rays unless the employee develops signs and symptoms suggestive of TB. If the employee is unable to obtain a copy of his/her negative chest x-ray report, a chest x-ray should be performed as a baseline and submitted with TB Core Health History, ODH Form 245, to the OSDH TB Medical Consultant for evaluation. TB forms are located in the TB Manual. The employee may choose to be evaluated by his/her private physician. A copy of the negative chest x-ray interpretation should be kept as part of the Employee Medical Record. Annually, the employee should be questioned regarding signs and symptoms of illness using Tuberculosis Questionnaire, ODH Form 247.
An employee with a documented positive tuberculin skin test (TST) and history of an abnormal chest x-ray and/or report should have TB Core Health History, ODH Form 245, and other portions of the Adult Health Record (as designated by current protocol), opened and be evaluated by the OSDH TB Medical Consultant or a private physician. The OSDH TB Medical Consultant will determine the need for a repeat chest x-ray. These records must be maintained as part of the Employee Health Record.
4. TB Mask Fitting- All employees and DOT providers working with active, suspected or potential TB clients must wear disposable particulate respirator (DPR) masks. Different DPRs are indicated for employees and for clients and are not interchangeable. Employees must be fitted for the appropriate size of DPR, which has a National Institute for Occupational Safety and Health (NIOSH) rating of N95 or greater. The DPR mask used must be capable of forming a seal around the nose and mouth area of the employee‘s face. This is documented on TB Mask Issuance Record, ODH Form 809, which is located in Appendix 1-A and is to be kept as part of the Employee Medical Record. The form does not require a physician signature unless the employee has a medical condition that requires physician evaluation or has difficulty with the test and is referred to a physician for evaluation (OSHA 1910.134.App A). Using the Annual Mask Fit Evaluation Form, ODH Form 285, the employee should be evaluated to determine if there has been gain or loss of 10% or more of body weight, use of dentures, beard /mustache or any facial surgery.
If any of the five questions are answered YES, the employee must be refit for an appropriately fitting DPR. The employee must not be allowed to provide services to a TB client until they have been refit and have an appropriately fitting disposable particulate respirator on hand to use.
If the employee provides information in the comments portion of the form that indicate a problem with the mask that was previously issued to them, the District Nurse Manager (DNM) must address those issues or concerns to a satisfactory resolution before the nurse will be allowed to provide service to a TB client. 2011 Infection Prevention and Control Manual 4
If all answers to the questions 1-5 are NO, it will be presumed that the DPR the employee is currently using is a proper fitting respirator and no further mask fit testing will be required at that time.
If the employee does not indicate any problems or concern with the mask in the comment area, it will be presumed the disposable respirator they were previously issued is still an appropriate fitting DPR and repeat mask fit testing will not be required at that time.
In signing the form, it is understood that the DNM/designee takes responsibility to see that the employee who has indicated the need to have repeat mask fit testing performed, will be refitted immediately. If re-fitting is not available immediately, the signature indicates it is understood that the employee is not to provide services to a TB client until they are refit tested and have an appropriately fitting disposable particulate respirator on hand for use.
5. TB Contact- If an employee has unprotected contact to an active, untreated TB case, a tuberculin skin test (TST) should be administered immediately (unless tested within the previous month) and repeated 3 months after the exposure. If the employee is a previous TST reactor, they should be questioned regarding signs and symptoms of illness using Tuberculosis Questionnaire, ODH Form 247 rather than receiving a TST. Should the employee become symptomatic, they should be evaluated by collecting three (3) sputum specimens for acid-fast bacilli (AFB) smear and culture and obtaining a PA and lateral chest x-ray. Submit the chest x-rays with a TB Core Health History, ODH Form 245, to the OSDH TB Medical Consultant for interpretation. An Incident Report, ODH Form 33, must also be completed and routed appropriately.
Immunizations
Guidelines for Vaccination of Employees
The following vaccines are required for employees whose job duties place them at risk, and for those who cannot provide proof of adequate previous vaccination or immunity as documented by medical record or laboratory testing. Vaccines are to be made available without charge to all employees deemed to be at risk. These guidelines are also applicable for contract, seasonal or temporary employees. Any employee not in compliance with these guidelines should be placed in only low risk areas (i.e., away from direct client contact).
1. Rubella- Proof of immunity or one dose of a Rubella containing vaccination (MR or MMR vaccine) is required for all county health department personnel and all Central Office personnel who have direct client contact. Birth before 1957 is considered acceptable evidence of immunity to Rubella except for those female employees who can become pregnant. Pregnancy is a contraindication to vaccinating with Rubella.
2. Rubeola- Required for all county health department personnel and all Central Office personnel who have direct client contact, were born in 1957 or after, and who do not have one of the following: Documentation of physician-diagnosed measles disease; written documentation of two doses of measles-containing vaccine (MMR is the preferred vaccine); or, a blood test showing measles immunity. Pregnancy is a contraindication to vaccination against rubeola. 2011 Infection Prevention and Control Manual 5
3. Mumps- Proof of immunity or one dose of Mumps vaccine (MMR vaccine) is required for all county health department personnel and all Central Office personnel who have direct client contact. Birth before 1957 is considered acceptable evidence of immunity to Mumps. Pregnancy is a contraindication to mumps vaccine.
4. Hepatitis B- Employees at risk for Hepatitis B infection include those who are ‗reasonably anticipated‘ to have routine blood exposures in the normal course of their work. Appendix 1-C details the potential types of exposures and personnel who may be at risk of these exposures. Employees at greatest risk include:
a. Those with daily exposure to blood or blood products by venipuncture.
b. Those exposed to blood or blood products in high-risk areas (i.e., STD clinics).
c. Laboratory and dental personnel with frequent contact to blood, blood products or other body fluids.
Within 10 days of employment, employees at risk must document their hepatitis B vaccination status on page 3 of ODH Form No. 807 (Occupational Health Record, Employee Screening Record, and Hepatitis B Vaccination Status). This form is available to central office employees through the Occupational Health Nurse. County health department employees should receive this form as a part of the New Employee Packet or through their local District Nurse Manager. Note that training on the risk of infection with bloodborne pathogens must have been provided prior to the date of the employee‘s declination. Employees who provide documentation of previous infection with hepatitis B (anti-HBc positive) have no need for vaccine.
Documentation of an anti-HBs titer that is greater than or equal to 10mIU/ml will be accepted as proof of immunity to Hepatitis B. Nonresponders to a previous complete Hepatitis B vaccination series should receive a second complete Hepatitis B vaccine series. Following the second series, those who continue to be nonresponders should be considered susceptible to Hepatitis B viral (HBV) infection, and should be counseled regarding precautions to prevent HBV infection and the need to obtain Hepatitis B immune globulin (HBIG) prophylaxis for any known exposure to hepatitis B surface antigen (HbsAg) positive blood. Testing for vaccine response is not available through OSDH Public Health Lab. County health department Administrators may choose to contract with a lab of their choice for (anti-HBs) vaccine response testing for their local employees for whom they administer the hepatitis B vaccinations, though this testing is not required. In the event that an exposure should occur, the employee may be tested at that time if no documentation exist confirming adequate titer.
5. Varicella (chickenpox)- All county health department personnel and Central Office personnel with client contact should be questioned regarding history of chickenpox. Those persons who do not have a reliable history of chickenpox disease, serologic evidence of disease, one dose of varicella vaccine on or after the first birthday prior to 2011 Infection Prevention and Control Manual 6
the 13th birthday, or two doses of varicella vaccine separated by at least 28 days on or after the 13th birthday, should be vaccinated against Varicella.
The following vaccinations are strongly recommended for employees:
1. A. Tetanus-Diphtheria- After primary immunization, a tetanus-diphtheria booster
is recommended for all persons every 10 years. Primary immunization of adults consists of three doses of adult tetanus-diphtheria toxoid (TD); 4-5 weeks should separate the first and second doses, with the third dose given 6-12 months after the second.
1. B. Tetanus-Diphtheria and Pertussis (Tdap) Adacel-A single dose of Adacel vaccine may be used to replace a single dose of Td for booster immunization against tetanus, diphtheria and pertussis in adults 19 through 64 years of age. Tdap vaccination is recommended for adults who have close contact with infants.
For female employees who are pregnant, the ACIP recommends vaccination with Td during pregnancy.
2. Influenza- Influenza vaccination is the most effective method for preventing the infection and transmission of influenza. The ACIP recommends influenza vaccination amongst health-care personnel (HCP) to be one of the measures of a patient and community safety quality program. All health-care personnel are encouraged to receive annual vaccination against influenza.
3. Rabies- Rabies vaccine may be indicated for persons in high-risk groups, such as veterinarians, animal handlers and certain laboratory workers.
Immunocompromised Employees
Immunocompromised individuals may be susceptible to infections of various types. Due to their weakened or depressed immune systems, they may have a more severe course of infection. Individuals may be immunocompromised for various reasons such as chemotherapy or irradiation for a neoplasm, medication use after an organ transplant to prevent rejection, long-term steroid therapy or Human Immunodeficiency Virus (HIV) infection.
Employees known to be immunocompromised should be placed in a location that will minimize potential for exposure to infectious disease. In addition, it is important to ensure that they are protected as much as possible through immunization. However, no immunizations should be administered to an immunocompromised employee without a direct order from the employee‘s physician.
Health Education and Counseling
Annual Bloodborne Pathogen Training
The OSDH must ensure that all employees with potential for occupational exposure to blood or body fluids participate in training programs. This training is essential to 2011 Infection Prevention and Control Manual 7
OSHA compliance. The programs must be provided at no cost to the employee, during work hours, with material appropriate to the education, literacy and language of the employee. It is the employees‘ supervisor‘s responsibility to see that the training is provided within 10 days of employment and within one year from the initial previous training. All employees must receive training annually, with additional training if changes are made that affect the employee‘s occupational exposure. The training is to be documented on the OSHA training record, ODH form N47, which is located in public folders. The completed sign in sheet is to be faxed 405.271.3539 to Training, Education & Development Division of OSDH for filing.
To locate ODH Form N47 on Public Folders, click on Safety Program; Forms; ODH Form N47
The Employee Training Record (Appendix 1-D) is optional to be completed by the employee‘s supervisor or designee. The OSHA Training Record (N47), which documents the names and titles of attendees, the date of the training, course content, and the name of the trainer must be kept for a period of 3 years.
Annual TB Training and Counseling
All OSDH employees requiring annual TB skin testing will receive annual TB training regarding TB infection, transmission and control provided by their division. A review of TB epidemiology for the county with application to the county health department will occur. The training will include: a review of county health department TB control procedures, TB suspect client handling, respiratory isolation use and TB mask usage requirements for employees, clients and family members. Training in any new or revised TB control procedures will be given.
Counseling regarding TB risk factors and TB infection shall be available on a one-on-one basis to any county health department employee from the TB nurse or the DNM. This shall include specific job-related risks. Known immunocompromised employees shall be counseled by the DNM regarding the risk of exposure to active TB.
Occupational Illness and Injury Reporting
Incident Reporting
To locate ODH Form 33 on Public Folders, click Safety; Forms; ODH Form 33
An Incident Report, ODH Form 33, should be initiated and faxed to the Safety Officer at 405-271-3933 as soon as possible, and no later than 72 hours following the occurrence, completed with all required information and signatures. This form can be accessed on Public Folders. The form can be completed electronically, printed and signed; or you may print the form and complete hand written, and signed. This official report is necessary to file for worker‘s compensation benefits for post exposure follow-up. After all required signatures and information are obtained a copy of the completed and signed incident report must be faxed to the Safety Office at 405-271-3933. The original completed Incident Report will be maintained at the County Health Department or Service Area of the occurrence. 2011 Infection Prevention and Control Manual 8
Authorization for Medical Attention, ODH form 10M, should be completed by the supervisor and provided to the employee at the time that it becomes evident that medical evaluation or treatment is required following a work related injury or illness. This form is available through the OSDH Safety Office at 405-271-4479.
The Oklahoma Department of Labor (ODOL) requires each public sector employer to maintain and post a record of certain injuries and illnesses. The OSDH Agency Workers’ Compensation Office maintains these records and distributes a Site OK Form 300 – Log of Work-Related Injuries and Illnesses to each OSDH satellite location and County Health Department annually, prior to February 1st of each year. The OK Form 300 A – Summary of Work-Related Injuries and Illnesses shall be posted during the period of February 1 through April 30 at the central OSDH Office First Floor Safety Bulletin Board, and at each individual OSDH satellite location and County Health Department Safety Bulletin Boards. The OK Form 300 and OK Form 300 A shall be retained in the central OSDH Office, individual satellite locations and County Health Departments for five (5) years. The original OK Form 300 and OK Form 300 A are kept in the central OSDH Human Resources, Benefits/Workers‘ Compensation office. OSHA and DOL require the preservation and maintenance of employee medical and exposure records for at least the duration of employment plus thirty (30) years.
Contract Agencies/Employees
Contract Agencies
When a contract agency is utilized to provide services at a county health department or central office location and the service offered places the contract employee at risk of exposure to bloodborne pathogens, the contract agency must provide documentation of training and hepatitis B vaccination for those employees as required by the OSHA standard on bloodborne pathogens.
Contracts with agencies providing services which place their employees at risk where such services are offered directly by the contracting agency (i.e., community-based organizations) must include a statement of intent to meet the requirements of the OSHA standard on bloodborne pathogens.
Contract Employees
In the event an individual is contracted (not through an agency), the individual must document:
1. having received training on bloodborne pathogens.
2. having been vaccinated against hepatitis B, immunity to hepatitis B or refusal to take hepatitis B vaccine.
Alternately, the county health department may offer such training and vaccination before the employee begins work. 2011 Infection Prevention and Control Manual 9
Post-exposure Treatment for Contract Employees
Follow-up and treatment for contract employees who sustain an occupational risk exposure at an OSDH facility is the responsibility of the contracting agency or contract employee. However, the county health department administrator or central office service chief should ensure that follow-up is being provided. Student nurses are not considered contract employees; the responsibility is between the school and the student for testing.
*Follow-up and treatment for nursing students who sustain an occupational risk exposure at an OSDH facility is the responsibility of the student and/or their school of nursing.
Protection from Bloodborne Pathogens
Personal Protective Equipment
To locate the Job Specific PPE list see Safety Program; Safety Manual; Job Specific Protective Equipment
OSHA standards require employers to provide protective equipment (PPE) when employees are at risk of exposure to bloodborne pathogens, but also when there is risk to encounter hazards that are capable of causing injury by absorption, inhalation or physical contact. This equipment includes protection for eyes, face, head and extremities, protective clothing, respiratory devices and protective shields and barriers. A lab coat/jacket is required for all client contact but is not considered PPE. The equipment is to be maintained in a sanitary, reliable condition.
Safety Devices
To locate the Retractable Safety Syringe Policy on Public Folders, click on Safety Program; Safety Manual; Retractable Safety Syringes
On December 1, 2004, OSHA published revisions to the Bloodborne Pathogens Standard in the Federal Register. At the mandate of the ODOL, OSDH Safety Committee has worked to meet these requirements, by evaluating and implementing appropriate engineering controls and work practices to prevent or minimize exposures to bloodborne pathogens. The specific engineering controls and work practice controls used are outlined in the Exposure Control Plan. An agency wide memorandum was processed, which has become the directive for safety device use by OSDH employees. This policy is located on Public Folders and is in Appendix 1-E.
Employee Medical Records
Employee medical records must be kept in a locked, secured cabinet, separate from all other records. Employee medical records are kept by the agency for 30 years following termination of the employee. The employee has a right to access his/her medical record upon request. Employee medical records are to be maintained in accordance with the Employee Medical Records Policy located under Administrative Policy Number 6-32. 2011 Infection Prevention and Control Manual 10
2011 Infection Prevention and Control Manual 11
Management of Occupational Exposure to Bloodborne Pathogens
n occupational exposure incident refers to a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood/ bloodborne pathogens or other potentially infectious materials that results from the performance of an employee‘s job duties. Potentially infectious body fluids include blood, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid and amniotic fluid. Feces, nasal secretions, saliva, sputum, sweat, tears, urine and vomitus are not considered potentially infectious unless they contain visible blood.
Percutaneous and non-intact skin exposures are defined as the introduction of blood or other potentially infectious body fluids directly through the skin (i.e., puncture or cut by sharp contaminated objects or introduction of blood or potentially infectious body fluids on areas where skin integrity is compromised).
Mucous membrane exposures are defined as the introduction of blood or potentially infectious body fluids directly onto the mucous membranes of the eyes, nose or mouth.
Management Plan (See Appendix 2-K)
Treatment of Exposure Site
Employees who sustain an occupational exposure (as defined above) should immediately address the exposure site.
1. Wounds and skin sites that have been in contact with blood or body fluids should be washed with soap and water.
2. Mucous membranes that have been in contact with blood or body fluids should be flushed using an eyewash station. Please refer to Section 3 for Eyewash Station Requirements.
Section
2
A 2011 Infection Prevention and Control Manual 12
No evidence exists that using antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk of bloodborne pathogen transmission; however, the use of antiseptics is not contraindicated. The application of caustic agents (i.e., bleach) or the injection of antiseptics or disinfectants into the wound is not recommended.
Reporting an Exposure
County health department employees who sustain an occupational exposure should immediately report to the DNM, Coordinating Nurse or Lead Nurse. Central office staff who sustains an occupational exposure should immediately call the Occupational Health Nurse at (405) 271-5180. If the source client is present in the clinic, the client should be requested to remain in clinic until plans for follow-up have been quickly assessed. This will facilitate obtaining additional blood samples on the source client if needed.
A Post-exposure Counseling Check Sheet may be used to assist the person responsible for managing the exposure. This form is located in Appendix 2-A.
To locate ODH Form 33 on Public Folders, click Safety; Forms; ODH Form 33
An Incident Report, ODH Form 33, should be initiated and faxed to the Safety Officer at 405-271-3933 as soon as possible, and no later than 72 hours following the occurrence. This form can be accessed on Public Folders. There are two versions of the form available, one to be electronically completed, and one for manual completion. Either are appropriate in the case of an occupational exposure. This official report is necessary to file for worker‘s compensation benefits for post exposure follow-up. After all required signatures are obtained, the completed report should be faxed to the Safety Officer at 405-271-3933. The original is maintained at the County Health Department.
The employee‘s supervisor should provide the employee with an Authorization For Medical Attention, ODH Form 10M, at the time that it becomes evident that further medical evaluation is required.
The Occupational Exposure Report, ODH Form 811, should be completed and is to be kept as part of the Employee Medical Record. This form is available through the local DNM or the Occupational Health Nurse.
When an employee has sustained an exposure, consultation for management of the exposure is available from the agency Occupational Health Nurse, 405-271-5180.
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Testing
1. Testing- Testing of the exposed employee and source client for HIV, Hepatitis C. ALTand/or Hepatitis B is indicated. Regardless of the potential risk, any exposed employee has the right to request or decline testing. If an employee declines testing after an exposure, that needs to be documented on the ODH 811, Exposure Report and on the Incident Report. The Oklahoma Public Health and Safety Code, 63 O.S., 1992, Section 1-502.3 allows for testing available blood of the source client and release of the results without the client‘s consent when a written report of an exposure has been made. However, the source client should be informed of the intent to test and the rationale for testing. Source Client Information located in Appendix 2-C, should be reviewed with the source client during the postexposure counseling session.
In the event that source blood has not been drawn and the source client refuses to allow blood to be drawn, contact the Occupational Health Nurse at (405) 271-5180 for consult. If indicated, a court order can be obtained to allow blood to be drawn. However, before going to that extent, a careful review of the circumstances would need to be made by the Occupational Health Nurse, OSDH State Health Officer or designee and OSDH Legal Services.
a. Test Requisitions-
OSDH currently has a contract in place with a contract lab for Hepatitis B & Hepatitis C testing. The lab requisition must be marked identifying the specimens as “Occupational Health” when submitting the specimens. The ICD 9 code: V15.85 is the code for exposure to potentially hazardous body fluids. This code must be added to the lab requisition when submitting ―Occupational Health‖ exposure lab specimens. A separate Specimen Referral Log should be kept in a folder in the same locked file cabinet as the Employee Medical Records. Only the persons with authorized access to the Employee Medical Records should have access to and document on this form.
Human immunodeficiency virus (HIV) testing of both the exposed employee and the source client is performed by the OSDH Public Health Laboratory Service. Do not enter the employee information into the Public Health Oklahoma Client Information System (PHOCIS) computer program. A manual copy of the Public Health Laboratory (PHL) requisition must be completed for the employee specimen. All PHL requisitions related to occupational exposure must indicate “Occupational Health”. Send HIV test specimens with appropriate ODH requisition forms to:
Oklahoma State Department of Health
Public Health Laboratory
1000 N.E. 10
PO Box 24106
Oklahoma City, Ok 73117
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b. Blood Specimen Collection-
Hepatitis- One full serum separator tube per person is sufficient to complete testing for both Hepatitis B and Hepatitis C. The blood should be spun down and the tube should be clearly labeled with the donor name, date of specimen collection, name of test requested and clinic site number. Specimens should be carefully packaged to prevent leakage or breaking. The outer package must be labeled as biohazardous.
Hepatitis B and Hepatitis C lab specimens for employees and source clients associated with an occupational exposure are to be sent to the contract lab for processing. The exposure source should be tested for the surface antigen (HbsAg) and the employee should be tested for surface antibodies (HbsAb).
HIV- One full serum separator tube should be drawn for HIV testing. The blood should be spun down and the tube should be clearly labeled with the donor‘s name, date of specimen collection, name of test requested and clinic site number. Specimens should be carefully packaged to prevent leakage or breaking. The outer package must be labeled as biohazardous.
A manual copy of the requisition should be copied from the Public Health Laboratory Resource Manual for use on occupational exposures. The requisition for such test should not be printed from the computer in order to protect the employee’s confidentiality.
Before submitting the specimen, the lab requisition must be marked as an Occupational Health test at the top of the page on the right-hand corner. This alerts the lab personnel to the reason for the manual requisition. CompSource should be listed in the insurance section of the form to ensure proper billing to worker‘s comp.
c. Release of Test Results-
Health Insurance Portability and Accountability Act of 1996 (―HIPAA‖) apply to all parties in an exposure testing situation. Only those persons directly involved in the exposure incident are to be informed of test results. This normally would include only the source client, the exposed employee and whomever the employee designates such as the DNM or designee.
Source client test results may be released to the exposed employee, the DNM, designee and Occupational Health Nurse without the expressed written consent of the source client per Oklahoma state law requiring documentation of occupational exposures.
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Exposed employee test results are not to be released to any person or facility, other than the Occupational Health Nurse, DNM or designee without the expressed written consent of the employee (OSHA: CFR 1910.1030 (h.) Medical Records). It is not necessary for source client name, code number or test results to be released on worker's compensation claims in order for the claim to be processed. Claims related to seroconversion of the exposed employee would necessitate release of source client test results, but not source client name.
d. Filing of test results-
The exposed employee‘s test results are to be kept as part of the Employee Medical Record. The source client‘s test results are not to be filed in the Employee Medical Record. A separate folder, which contains source client test results, should be kept in the same locked cabinet as the Employee Medical Record.
Exposure Evaluation for Counseling
In order to counsel the exposed employee regarding the risk of contracting a communicable disease following the exposure, the DNM or designee, should evaluate the exposure based on the type of body substance involved and the route and severity of the exposure.
Percutaneous injuries- Injuries resulting from solid needles or superficial injuries are considered LESS SEVERE. Injuries resulting from large bore hollow needles, deep punctures, and visible blood on the device or a needle used in a client‘s artery or vein is considered MORE SEVERE.
Mucous membrane exposures- Consider volume of fluid involved. A few drops poses LESS RISK than a major blood splash.
Skin exposures- Follow-up is indicated only if there is evidence of compromised skin integrity (i.e. dermatitis, abrasion, or open wound).
Human bites- Follow-up should be provided to both the person bitten and the person who inflicted the bite when the bite results in a blood exposure.
Source Client Evaluation
The person whose blood or body fluid is the source of an occupational exposure should be evaluated for HIV, hepatitis C (HCV), and/or hepatitis B (HBV) infection as indicated. If the HBV, HCV, and/or HIV infection status of the source is unknown, the source should be informed of the incident and tested for serologic evidence of infection.
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Tests to be requested for the source client may include: HbsAg: Hepatitis B surface antigen anti-HCV: Hepatitis C antibody HIV-EIA: Human Immunodeficiency virus antibody
If the exposure source is unknown or cannot be tested, information about where and under what circumstances the exposure occurred should be assessed for likelihood of transmission of HIV. Testing of needles or other sharp instruments implicated in an exposure is not recommended.
Information to consider when evaluating an exposure source would include previously documented laboratory tests, presence of clinical symptoms of HIV and history of recent (within previous three months) possible exposure to HBV, HCV, and HIV (i.e., injection drug use, or sexual contact with a known positive partner). Appendix 2-D includes information to assist in assessing risk factors.
Management and Follow-up of Potential Exposure to HBV
Following an exposure, the Hepatitis B vaccination status and the vaccine response status (if known) of the exposed person should be reviewed. If the exposed employee has had a previous titer (anti-HBs) with a response equal to or greater than 10 mIU/mL then there is no need to test for Hepatitis B surface antigen. If the vaccination and antibody response status of the exposed employee is unknown then a (HbsAb) Hepatitis B surface antibody (qualitative) test needs to be done at the time of exposure. A summary of Hepatitis B prophylaxis recommendations is located in Appendix 2-E. Adequate antibody response following Hepatitis B vaccination is defined as an anti-HBs response of equal to or greater than 10 mIU/mL.
A ―qualitative‖ Hepatitis B Surface Antibody Test is acceptable if the processing lab can verify that an ―immune‖ response represents an antibody response of 10 mIU/ml or greater.
The vaccinated employee is referred to as a known responder (anti-HBs equal to or greater than 10 mIU/mL), non-responder (anti-HBs less than 10 mIU/mL after two complete series of Hepatitis B vaccine), or response unknown (anti-HBs result unknown).
When Hepatitis B Immune Globulin (HBIG) is indicated for a non-responder or employee with an unknown response, the county health department should determine the most expedient resource to secure it. The county health department may consult with the Occupational Health Nurse to determine the need and possible resources. HBIG should be administered as soon as possible after exposure (preferably within 24 hours), but may be administered up to 7 days post exposure.
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In the case of an exposed employee who is a known responder, testing the source for HbsAg is not necessary.
Appendix 2-F includes information to share with the employee who is exposed to HbsAg positive or high-risk clients.
Management and Follow-up of Potential Exposure to HCV
Currently, no data exists which shows that either Immune Globulin (IG) or use of antiviral agents is effective in preventing HCV. Rather, postexposure management for persons potentially exposed to hepatitis C virus is aimed at achieving early identification of chronic disease and, if present, referral for evaluation of treatment options.
Testing for the employee exposed to an HCV-positive source should include: Initial baseline anti-HCV and ALT 6 months post-exposure anti-HCV and ALT
Confirmatory testing should be performed on all positive anti-HCV results.
Management and Follow-up of Potential Exposure to HIV
The county health department employee who sustains an exposure should be evaluated immediately by the DNM or designee and blood should be collected for baseline HIV testing. The employee‘s baseline blood sample may be tested immediately or held for up to 90 days. The employee has the right to refuse HIV testing and follow-up.
If the source person is seronegative for HIV and denies symptoms of acute viral illness (fever, rash, myalgia, fatigue, malaise or lymphadenopathy), baseline testing or further HIV follow-up of the exposed employee is not necessary, but should be made available if the exposed person is concerned.
Recommended follow-up for potential exposure to HIV is based on current Centers for Disease Control (CDC) guidelines. Recommended HIV prophylaxis is based on results of the source blood testing. These recommendations are located in Appendix 2-G and 2-H.
Health department employees who sustain an exposure to a source person with HIV infection or a source person with clinical evidence of AIDS or symptoms of HIV infection should:
1. Be counseled regarding the risk of transmission and the potential efficacy of postexposure (PEP) medications. Postexposure evaluation and treatment with PEP meds may be obtained at either the employee‘s private physician or through the local emergency room, depending on resources available in that particular county. It is important to note that evaluation and 2011 Infection Prevention and Control Manual 18
treatment should not be delayed when indicated. When the employee is referred for postexposure evaluation and treatment, the employee should take the following items:
a. copy of ―Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis‖ MMWR, September 30, 2005/54(RR9);1-17.
*A copy of this document can be accessed at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm. Print a copy of this document to have on hand, which can be used by the physician when evaluating the need for PEP.
A copy of ―Notice to Readers‖: Updated Information Regarding Antiretroviral Agents used as HIV Postexposure Prophylaxis for Occupational HIV Exposures‖, MMWR. December 14, 2007/56(49);1291-1292. This document can be accessed at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5649a4.htm.
b. Copy of the OSDH Referral Policy: Postexposure Prophylaxis Appendix 2-I.
2. Be advised to seek medical evaluation for any acute febrile illness occurring within 12 weeks of exposure. Acute illness, particularly if characterized by fever, rash, myalgia, fatigue, malaise or lymphadenopathy, may be indicative of recent HIV infection.
3. Follow recommendations for preventing transmission of HIV until subsequent testing rules out HIV transmission to the employee. Appendix 2-J includes information for the employee who is exposed to HIV positive or high-risk clients.
The employee who is exposed to HIV should receive HIV-EIA testing at: baseline, 6 weeks, 12 weeks and 6 months
Extended HIV follow-up testing should be performed at 12 months for employees who become infected with HCV following exposure to a source that is coinfected with HIV and HCV.
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Infection Prevention Practices
s early as 1977, recommendations were published regarding isolation precautions used in healthcare settings to prevent spread of disease. Many changes have followed, and the current document is the ―Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007‖, created by the Healthcare Infection Control Practices Advisory Committee (HICPAC), a federal advisory committee that advises and develops guidelines Centers for Disease Control and Prevention (CDC) and the Secretary of the Department of Health and Human Services (HHS) regarding health care infection control and prevention. This revision addresses home care and ambulatory care settings for the first time as well.
As of 2008, the terminology has evolved from ―infection control‖ to ―infection prevention‖, as the priority has shifted to preventing the occurrence of healthcare-associated infections. Additionally, the Association for Professionals in Infection Control and Epidemiology (APIC) announced that infection control professionals would now be referred to as ―infection preventionists.‖The latest HICPAC guideline divides precautions into three categories. Standard Precautions are based on the principal that all blood, body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes may contain contagious infectious agents. Standard precautions are used with all clients regardless of known disease status. Standard precautions include Respiratory Hygiene/Cough Etiquette, Safe Injection Practices and Infection Control Practices for Special Lumbar Puncture Procedures.
When Standard Precautions cannot completely interrupt the route of transmission of a known or suspected agent, the expanded Transmission-Based Precautions are used. There are three types of Transmission-Based Precautions: Airborne Precautions, Droplet Precautions, and Contact Precautions. Since many infections require laboratory confirmation, certain clinical syndromes and conditions are sufficient to warrant implementation of Transmission-Based Precautions while confirmatory tests are pending. This application of Transmission-Based Precautions is referred to as Syndromic/Empiric Precautions.
Standard Precautions
Use Standard Precautions for the care of all clients.
1. Hand hygiene- Includes both hand washing and use of alcohol-based products to be used without water. Perform appropriate hand hygiene immediately before and after client contact. Perform hand hygiene after touching blood, body fluids, secretions, excretions, mucus membranes, nonintact skin, wound dressings, or inanimate objects in the immediate vicinity of the patient. Perform hand hygiene
Section
3
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immediately after gloves are removed. It may be necessary to perform hand hygiene between tasks and procedures on the same client to prevent cross-contamination of different body sites. Handwashing: Hands that are visibly soiled should be washed using either plain or antimicrobial soap and water. Wet hands with running water. Apply soap and thoroughly distribute over hands. Vigorously rub hands together for a minimum of 15-30 seconds, covering all surfaces of the hands and fingers. Rinse well and dry with an unused, dry towel or air dryer. Turn off faucet using dry towel. Avoid recontamination of hands on sink, sink components, or bathroom door handle after washing. Alcohol-based hand product (such as gel, rinse, or foam) method: May be used when hands are not visibly soiled. Apply a 60-95% ethanol or isopropanol alcohol based hand gel to the palm of one hand. Rub hands vigorously together, covering all parts of the hands until dry (usually about 30 seconds). Follow the manufacturer‘s recommendations regarding the volume of product to use. Because appropriate use of these products require less time, all OSDH sites should consider having this method available to improve hand-hygiene adherence. Alcohols are flammable; therefore, insure all alcohol has evaporated after using alcohol-based hand products, and store these products away from high temperatures or flames. Home visitors: It is recommended that home visitors carry liquid soap, paper towels and alcohol-based hand product for the purposes of hand hygiene, based on availability of running water. As stated above, hands that are visibly soiled should be cleaned using soap and water and dried well with paper towels.
Wash hands with soap and water or perform hand hygiene using alcohol-based hand product prior to weighing/measuring or other examination of infants and children in order to promote good hygiene and prevent the spread of bacteria.
After completing the home visit, the home visitor should use the alcohol-based hand product before entering his/her vehicle.
Washing hands with either plain or antiseptic-containing soap and water after use of an alcohol based hand product is not necessary and is not recommended, because it may contribute to dermatitis. Washing hands with soap and water after 5-10 applications of gel has been recommended by certain manufacturers for aesthetic purposes.
In order to maintain hand skin health, CDC recommends implementation of a routine schedule for applying lotions or creams. Avoid use of oil or petroleum-based hand lotions or creams which adversely affect the integrity of latex gloves and can contribute to latex sensitivity/allergy. Information should be solicited from the manufacturer regarding potential interactions with gloves. 2011 Infection Prevention and Control Manual 21
Antimicrobial-impregnated wipes or towelettes are not as effective as alcohol- based hand rubs or antimicrobial soap, and water for hand hygiene purposes, and should not be used as a substitute for hand hygiene in client care settings.
2. Fingernails and Artificial Nails - The subungual area (situated beneath the nail of a finger) of the hand harbors high concentrations of bacteria. Healthcare workers who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than those who have natural nails, both before and after handwashing. Therefore, artificial fingernails are discouraged in the clinical setting. All fingernails (artificial or natural) should be less than 1/4 inch long to reduce the colonization of the subungual area with bacteria. Freshly applied nail polish does not increase the number of bacteria recovered from periungual skin, but chipped nail polish may support the growth of larger numbers of organisms on fingernails.
3. Gloves- Wear gloves when touching blood, body fluids, secretions, excretions and contaminated items. Care must be taken to ensure that any hand jewelry does not interrupt the integrity of the gloves. Jewelry can cause tears in gloves and therefore it is recommended that jewelry be kept to a minimum when working in a client care environment. Gloves should be worn for specimen collection, cleaning and disinfecting client care equipment and environmental surfaces, handling contaminated personal protective equipment or clothing, or handling medical waste containers. Put on clean gloves just before touching mucous membranes and nonintact skin. Take care to avoid contaminating clean areas when wearing gloves.
Change gloves between tasks and procedures on the same client after contact with potentially infectious materials. Change gloves immediately if torn or the integrity of the glove is compromised. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another client. Perform appropriate hand hygiene immediately, because gloves can develop unnoticed holes or tears during use and hands may be contaminated. Wear the appropriate glove size to achieve a good fit. Latex sensitivity or latex allergy can develop following repeated exposure or use of latex items such as gloves, especially among healthcare workers. For this reason, the National Institute of Occupational Safety and Health (NIOSH) has these recommendations to minimize latex exposure (see reference section for document): Use nonlatex gloves when appropriate Use powder-free latex gloves with reduced protein content Wash hands thoroughly after removing gloves Use non-oil-based hand lotions or creams to avoid glove deterioration Thoroughly and frequently clean areas contaminated with latex-containing dust Recognize the symptoms of latex allergy: rash, hives, flushing, respiratory symptoms, asthma and shock. If you develop latex sensitivity or allergy, avoid contact with latex, notify your supervisor and consult a physician. 2011 Infection Prevention and Control Manual 22
4. Mask, Eye Protection, Face Shield- Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose and mouth during procedures and activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions. Select appropriate items as indicated by the task being performed. Examples of situations in which full-face protection would be indicated include culturing for pertussis, performing emergency OB-GYN exams, assisting in emergency childbirth or rendering first aid to a severely bleeding client. Full-face protection is indicated if it is reasonably anticipated that the client may cough in the face of the employee during collection of respiratory specimens. WARNING: Care must be taken when performing sharps procedures due to the reduced field of view when wearing protective masks. Visibly or suspected contaminated face protection must be changed whenever wet and between each client.
It is recommended that home visitors carry in their bag that is taken into the home a minimum of two disposable surgical masks. If the client is coughing, the home visitor should don a mask to protect himself or herself against droplet transmission. Under these circumstances, the visit may be completed as scheduled.
5. Lab Coat/Jacket- Wear a cloth or fluid resistant lab coat/jacket to protect skin and to prevent soiling of clothing during procedures and activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. General work clothes (i.e., uniforms, pants, shirts or blouses) are not intended to function as personal protective equipment. Remove a soiled lab coat/jacket as promptly as possible, minimizing contamination. If contaminated with blood or body fluids, the lab coat/jacket must be promptly replaced with a clean lab coat/jacket. Refer to Guidelines for the Work Setting, Management of Contaminated Non-disposable Lab Coats and Other Laundry in this section.
6. Footwear- Sandals, open-toed shoes, shoes with holes that expose the feet (including Crocs™), or shoes with open backs are not to be worn in any laboratory or client care areas in accordance with OSHA Bloodborne pathogen standard 1910.1030(d)(3)(i) and OSHA Personnel Protective Equipment Regulation 1910.132 OSHA interpretation of the use of Crocs™ brand shoes states that when a risk of foot injuries due to falling or piercing objects (such as needles) would be an environment which could cause foot injury and protective foot ware would be required.
7. Equipment/Environmental Control- Handle equipment that is soiled with blood, body fluids, secretions or excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing and transfer of microorganisms to one‘s self, other clients and environments. Contaminated needles and other contaminated sharps shall not be bent, recapped or removed. The current directive from OSHA, CPL2-2.69 at XIII.D.5 states, ―removing the needle from a used blood-drawing/phlebotomy device is rarely, if ever, required by a medical procedure. Because such devices involve the use of a double-ended needle, such removal clearly exposes employees to additional risk, as does the increased manipulation of a contaminated device.‖ In order to prevent potential worker exposure to the contaminated hollow bore needle at both the front and back ends, it is required that vacutainer holders with retractable technology be utilized for 2011 Infection Prevention and Control Manual 23
phlebotomy procedures. All vacutainer tube holders are to be considered single use and discarded after each use.
Ensure that reusable equipment is not reused for the care of another client until it has been cleaned and reprocessed appropriately. Use PPE appropriately when cleaning contaminated equipment. Ensure that single-use items are discarded properly. Follow Guidelines listed in Section 4 for decontamination and cleaning of equipment and environment.
8. Occupational Health and Bloodborne Pathogens- All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering and generation of droplets of these substances. Never recap used needles. Do not remove used needles from disposable syringes by hand, and do not bend, break or otherwise manipulate used needles. Immediately place used disposable syringes and needles in an appropriate puncture-resistant container that is labeled or color-coded [in accordance with CFR 1910.1030(d)(2)(vii)(B)], which should be located as close as practical to the area in which the items were used. Specimens of blood or other potentially infectious materials shall be placed in a container that prevents leakage during collection, handling, processing, storage, transport or shipping.
9. Eyewash Station Requirements- Eye wash stations must be provided in work areas where the eyes and body may be exposed to any injurious material or material containing bloodborne pathogens to provide immediate use in accordance with OSHA 1910.151 (c). An eyewash station must provide a controlled flow of water to both eyes simultaneously at a velocity low enough not to injure the user. It must deliver at least 3 gallons per minute for 15 minutes at a minimum of 30 psi (pounds per square inch) of flow pressure. It must be large enough to provide room for the eyelids to be held open with the hands while the eyes are in the stream of water. Emergency eyewash stations must be located where employees can easily access them, in a well-lighted area identified with a sign. It should be located in an area that requires no more than 10 seconds for employees to reach or approximately 100 feet. Activate weekly to flush the line, verify proper operation, and record on log.
10. Respiratory hygiene/cough etiquette- is included in Standard Precautions to address spread of undiagnosed transmissible respiratory infections. The components of respiratory hygiene/cough etiquette include (1) education of employees, clients and visitors regarding appropriate cough etiquette; (2) posted signs in appropriate languages describing the concepts; (3) source control measures such as appropriate use of a tissue, prompt disposal of used tissues, use of surgical or procedural masks on coughing clients; (4) hand hygiene after contact with respiratory secretions or items/surfaces contaminated with respiratory secretions; and (5) spacial separation, ideally >3 feet of symptomatic persons from others while in common areas such as waiting rooms.
11. Safe injection practices- include the basic aseptic techniques for the preparation and administration of injectable medications. These include use of sterile, single-use, disposable needles and syringes for each injection given and preventing contamination of medication and equipment. 2011 Infection Prevention and Control Manual 24
Transmission Based Precautions
See Table in Appendix 3-A for Type and Duration of Precautions to Use for Selected Infections and Conditions.
1. Airborne Precautions- In addition to Standard Precautions, use Airborne Precautions for clients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei, which remain suspended in the air over long distances. Examples include measles, chickenpox, tuberculosis, and possibly influenza and SARS. Such clients are priority clients and should be seen immediately. If the airborne infection isolation room is being used and other clients present to the clinic with signs and symptoms of an airborne transmissible disease, they should be given priority and the TB Nurse/nurse should be notified and see them as soon as possible. Alternately, these clients may be, sent outside of the building to wait, and should be monitored as potential flight or communicable disease risks if they do not adhere to instructions. Airborne droplet nuclei remain suspended in air and are dispersed widely by air currents indoors, but are diluted and destroyed by natural sunlight, making them much less likely to be a communicable disease risk outdoors. In the clinic setting, place the client in the airborne infection (negative airflow) isolation room. Keep the room door closed. Alternately instruct the client to remain outside in a designated location. Provide the client with a disposable surgical mask and instruct him/her regarding respiratory hygiene and cough etiquette. Provide tissues, waste container, and access to hand hygiene products. Wear respiratory protection (N95 respirator) when entering the room or home. See Section 6 for additional guidelines for working with clients with tuberculosis. Susceptible persons should not enter the room or the home of clients known or suspected to have measles or varicella if other immune caregivers are available. Due to difficulties in confirming definite immunity, the HICPAC guideline does not have a recommendation for health care workers who are immune or have been adequately vaccinated against measles or varicella, and are caring for a client who is infected or suspected with measles or varicella. The type of respiratory protection for immune healthcare workers is also an unresolved issue in the guideline. Therefore healthcare workers presumed to be immune should wear N95 respirators when caring for clients with suspected or confirmed measles or varicella.
2. Droplet Precautions- In addition to Standard Precautions, use Droplet Precautions for a client known or suspected to be infected with microorganisms transmitted by large particle droplets, which are spread through close respiratory or mucous membrane contact with respiratory secretions. The client can generate droplets during coughing, sneezing, talking, or singing. Examples of such illnesses include Haemophilus influenza type b, Neisseria meningitis, Diphtheria, Pertussis, Pneumonic plague, Streptococcal (group A) pharyngitis, pneumonia, Scarlet fever, Influenza, Mumps and Rubella. 2011 Infection Prevention and Control Manual 25
Instruct clients suspected to have a droplet spread illness on the use of Respiratory Hygiene/Cough Etiquette. Keep client separated from other clients. Place into an exam room as soon as possible. If delayed, place a surgical or procedure mask on the client and place him/her 3-6 feet from others. Wear a mask when entering the client‘s room. In the home setting, in situations where the visit cannot be rescheduled, use a mask when working within 3-6 ft. of the client.
3. Contact Precautions- In addition to Standard Precautions, use Contact Precautions for clients known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the client or indirect contact with contaminated environmental surfaces or items. Blood and body fluids are important sources of disease-causing organisms potentially spread through contact transmission. Examples include major draining wounds, Clostridium difficile, acute viral conjunctivitis, herpes simplex, lice, respiratory syncytial virus (RSV), and shingles (varicella zoster). Examples of chances for indirect contact transmission include hands that are not cleaned after becoming contaminated, patient-care devices that are not cleaned between patients, shared items such as toys among pediatric patients, and instruments that are not correctly cleaned between patients before disinfection or sterilization. Wear gloves for all interactions with the client, items belonging to the client or when touching surfaces potentially contaminated by the client. During the course of providing care for a client, change gloves after having contact with infective material. Remove gloves before leaving the room and perform hand hygiene immediately. Wear a cloth or fluid resistant lab coat/jacket if you anticipate that your clothing will have substantial contact with the client, or if the client is incontinent or has diarrhea, an ileostomy, a colostomy or wound drainage not contained by a dressing. Remove the cloth or fluid resistant lab coat/jacket before leaving the client‘s environment. Adequately clean and disinfect equipment according to guidelines in Section 4 prior to use for another client.
Infection Prevention and Control for Potential Bioterrorism Agents
As a consequence of the terrorist attacks on September 11, 2001 and the anthrax mail attacks that closely followed during October – November, 2001, public health workers assumed a leadership role in terrorism preparedness and response. It is recommended that all county health department administrators, nurses, and public health specialists familiarize themselves with the following list of potential bioterrorism agents and their respective transmission precautions. These agents cover a broad spectrum of biological pathogens, including bacteria, viruses and toxins. In some instances, it will not be possible for first responders to recognize which disease agent they are initially dealing with, or if it is a biological attack rather than a naturally occurring disease outbreak. When the agent is unknown, droplet precautions-- at a 2011 Infection Prevention and Control Manual 26
minimum--should be exercised when interacting with affected clients until the infecting agent can be confirmed by laboratory testing at the OSDH Public Health Laboratory or the CDC.
The CDC has categorized potential biological agents of terrorism into the following three categories:
Category A – potential agents include those that cause: anthrax; botulism; plague; smallpox; tularemia; and viral hemorrhagic fevers. These are high priority agents because the organisms pose a risk to national security due to the following characteristics: Can be easily disseminated or transmitted from person to person Result in high mortality rates and have the potential for major public health impact Might cause public panic and social disruption Require special action for public health preparedness
Category B – potential agents or resulting conditions include: Brucellosis; food safety threats (Salmonella, Escherichia coli, Shigella); Glanders; Q-Fever; Ricin toxin; Staphylococcal enterotoxin B; Typhus fever; Viral encephalitis (alphaviruses); and, water safety threats (Vibrio cholerae and Cryptosporidium parvum). These are considered second highest priority agents due to the following characteristics: Are moderately easy to disseminate Result in moderate morbidity rates and low mortality rates Require specific enhancements of CDC and state health departments‘ diagnostic capacity and enhanced disease surveillance.
Category C – potential agents include: emerging infectious disease agents such as Nipah virus and Hantavirus. These are considered the third highest priority due to the following characteristics: Availability Ease of production and dissemination Potential for high morbidity and mortality rates and major health impact
The public health work force should employ transmission-based precautions when handling clients where a bioterrorism event is suspected or confirmed. A higher level of precautions may be required to safely handle environmental specimens contaminated with a biological agent. It should also be noted that human cases of anthrax, botulism and tularemia occur sporadically in our state from natural exposures. For guidance in these situations, contact the Acute Disease Service Epidemiologist-on-Call at 405-271-4060. Calls to this number after business hours, weekends and holidays will be returned within 15 minutes. 2011 Infection Prevention and Control Manual 27
Isolation Precautions for Bioterrorist Agents
Standard
Contact
Droplet Precautions
Airborne
CATEGORY A - Potential Agents
Anthrax (B. anthracis), Botulism (C. botulinum toxin), Tularemia (F. tularemia)
X
Pneumonic plague (Yersinia pestis)
X
X
Smallpox (Variola major virus)
X
X Viral Hemorrhagic Fevers (VHFs) Marburg, Ebola, or Arenaviruses
X
X
X
X
CATEGORY B & C - Potential Agents
Brucella spp. (Brucellosis), Salmonella, Escherichia coli, Shigella, Burkholderia mallei (Glanders), Coxiella burnetti (Q-Fever), Staphylococcal enterotoxin B, Rickettsia prowazekii (Typhus fever), alphaviruses (Venezuelan Equine Encephalitis, Eastern Equine Encephalitis) , Vibrio cholerae (Cholera), Cryptosporidium parvum (Cryptosporidiosis), Ricin toxin, Nipah virus, and Hantavirus
X
See Table in Appendix 3-A for Type and Duration of Precautions to Use for Selected Infections and Conditions.
Guidelines for the Work Setting
1. When there is the risk of occupational exposure, the employer shall provide, at no cost to the employee, appropriate protective equipment such as, but not limited to, gloves, gowns, laboratory coats, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks or other ventilation devices. Personal protective equipment will be considered ―appropriate‖ only if it does not permit blood or other potentially infectious materials to pass through to or reach the employee‘s works clothes, street clothes, undergarments, skin, eyes, mouth or other mucous membranes under normal conditions of use for the duration of time, which the protective equipment will be used [CFR 1910.1030 (d)(3)(i)]. 2011 Infection Prevention and Control Manual 28
2. The employer shall ensure that the employee uses appropriate personal protective equipment unless the employer shows that the employee temporarily and briefly declined to use personal protective equipment when, under rare and extraordinary circumstances, it was the employee‘s professional judgment that in the specific instance its use would have prevented the delivery of health care or public safety services or would have posed an increased hazard to the safety of the worker or co-worker. When the employee makes this judgment, the circumstances shall be investigated and documented in order to determine whether changes can be instituted to prevent such occurrences in the future [CFR 1910.1030 (d) (3) (ii)].
3. Use of Personal Protective Equipment/Clothing- Personal protective equipment and clothing is designed to place a fluid-resistant barrier between the health care provider and the blood or other body fluids of the client. All such equipment and clothing must be provided and maintained by the county health department administration. Employees are not to take contaminated personal equipment or clothing home under any circumstances or for any purpose, nor are they to wear it outside of the clinic area.
4. Management of Client Specimens-
a. Handling: To avoid contamination of environmental surfaces and exposure to the employee, client specimens must be handled with care to prevent breakage, spillage or contamination of outer container. Gloves must be worn. Immediately clean any spills that occur, following guidelines found in Section 4 of this document.
b. Transport and Mailing: Blood specimens must be collected in the appropriate water tight, sealed tube and placed in a sealed water tight plastic bag. The bag must contain sufficient absorbent material. The bag must be placed in an outer shipping container that is made from fiberboard or equivalent material. The container must be labeled as biohazardous and should state that the package complies with 42 CFR 72.3 (d) of the Postal Regulations. See the Public Health Laboratory Resource Manual for additional instructions.
5. Management of Contaminated Non-disposable Lab Coats and Other Laundry- Gloves and other appropriate protective apparel should be worn by persons handling contaminated clothing. Once contaminated, non-disposable lab coats or any other clinic laundry must be placed in a fluid-resistant container that is red in color and/or marked with the universal biohazard symbol. Washing in hot water in a standard automatic washing machine is sufficient for decontamination. Adding bleach to the wash cycle is not required. Since employees cannot take these items home, the OSDH or County Health Department must ensure the laundry is done on site, taken to a local self-service laundry, or taken to a commercial laundry. Commercial dry-cleaning of fabrics soiled with blood also renders these items free of the risk of pathogen transmission. If a commercial laundry is used, contaminated laundry must be transported in colored or labeled containers or bags as indicated above, and the laundry must be informed if they are receiving contaminated items. It is recommended that only those commercial laundries, which are known to be implementing the OSHA Bloodborne Pathogen Standard, be used. Lab coats that are soiled with dirt and not visibly contaminated by body fluids may be taken home by the employee for laundering. 2011 Infection Prevention and Control Manual 29
If clothing becomes contaminated during a home visit, and spare clothing is available, change into clean clothing and carefully place contaminated clothing into a plastic bag. If spare clothing is not available, place a disposable impervious gown over clothing and return home to change into clean clothes, showering if gross contamination occurred. Notify your supervisor as soon as feasible.
6. Work Areas- Eating, drinking, smoking and personal grooming are prohibited in work areas where there is a reasonable likelihood of occupational exposure. Also, food and drink may not be stored in a refrigerator, freezer, or other container or shelf where any medication or client specimens such as blood or other potentially infectious materials, are stored. A sign should be placed on the door of these areas, which indicates that no food or drink is allowed. CLIA regulations may place additional restrictions on management of laboratory specimens. Consult with the Public Health Laboratory, (405) 271-5070 for clarification if needed. 2011 Infection Prevention and Control Manual 30
2011 Infection Prevention and Control Manual 31
Guidelines for Cleaning, Disinfecting and Sterilizing
isted below are recommended procedures for management of equipment in county health department clinics, and equipment used in the home setting. In following the recommendations, it should be noted that household bleach solutions are less effective as disinfectants in the presence of high concentrations of protein. Hence it is important to first remove as much body fluid as possible before decontamination. Depending on the degree of contamination, the difficulty penetrating the contaminated area, and the ability of the surface to withstand exposure to bleach solution, a 1:10 to 1:100 dilution of bleach may be used. Contaminated containers or equipment that routinely store client specimens (i.e., centrifuges, freezers or refrigerators holding specimens, etc.) must be labeled as biohazardous using an adhesive biohazard label or a securely attached biohazard tag. Check manufacturer‘s directions before cleaning equipment. Contaminated equipment, supplies or environmental items that cannot be adequately disinfected should be removed from use, labeled as biohazardous using an adhesive biohazard label or securely attached biohazard tag and processed per manufacturer recommendations.
Product Sterility and Shelf-life
Sterility of a product, either purchased or packaged by OSDH, is event related. Nurses have a responsibility to use guidelines and good nursing judgment when evaluating products and packaging. Products, such as VanishPoint syringes, may contain a shelf-life date. This is usually the date the manufacture guarantees sterility of the product. The Association for the Advancement of Medical Instruments standards summarize product sterility as event related under intact packaging guidelines. Events that may compromise the sterility of a package include:
1. Multiple handling that leads to seal breakage or loss of package integrity,
2. Moisture penetration,
3. Airborne contaminants.
Section
4
L 2011 Infection Prevention and Control Manual 32
Prior to use, examine the equipment package for evidence of loss of integrity. Discard any single-use devices that have been exposed to floodwaters or have evidence of exposure of uncertain history, even if the packaging and seals appear to be intact.
Disinfectant Solutions
1. 1:10 dilution household bleach- 1 part household bleach to 9 parts water. May be made in quantity for one-week use. Label with expiration date.
2. 1:100 dilution household bleach- 1 part household bleach to 99 parts water. Must be made daily and discarded at the end of the day to assure effectiveness. 1 oz. household bleach in 3 quarts water makes an actual dilution of 1:97, which is acceptable.
3. Other solutions- Any commercial disinfectant labeled as Tuberculocidal when diluted according to manufacturer‘s specifications.
4. 1:10 Disinfectant Wipes- Disposable disinfectant wipes meeting a 1:10 dilution of household bleach are considered an acceptable disinfectant product. Use according to package directions.
Note that there is an association between the excessive use of a phenolic disinfectant and hyperbilirubinemia in newborns. A phenolic product must not be used on surfaces that may come in contact with infants.
General Area Maintenance
1. Office Area- The area should be kept neat and dust free when possible. Regular vacuuming and/or mopping is recommended. Routine cleaning and disinfection of office equipment, such as the telephone handset and countertops is recommended to help prevent the spread of viruses in office settings.
2. Client Waiting Areas and Restrooms- Thorough environmental cleaning of client waiting areas and restrooms should be done routinely with a disinfectant solution. Waiting area floors and items found in the waiting area such as chairs, and tables should be cleaned and disinfected daily. Clients should be encouraged to bring their own toys from home when necessary. Chairs in client waiting areas should be spaced in such a manner as to avoid body contact between seated individuals. Only the client should handle the client‘s clothing and outerwear. Devices such as coat trees should not be available in client waiting areas. Optimally, individual outerwear should be kept with the client or placed on wall hooks 12 inches apart. Employee‘s outerwear should be managed in the same manner as that of clients. Clients recognized to have a disease spread by contact transmission, such as skin infections or scabies, should be directed to an area away from other clients. For guidelines regarding clients who are coughing, see Section 5 “Guidelines For the Prevention of Respiratory Transmitted Diseases”.
Restroom items such as toilet stalls, sinks and floors should be cleaned and disinfected daily and when visibly soiled. 2011 Infection Prevention and Control Manual 33
3. Work Areas and Equipment Surfaces- Clinic room tables, countertops, floors and sinks should be cleaned and disinfected daily and when visibly soiled. Equipment used for home visits, such as portable scales, should be disinfected between client visits. After each client clean visible blood and body fluid spills from all exam tables and infant scale pans with detergent and water, then decontaminate with 1:10 dilution of household bleach solution or an approved disinfectant. Rinse with clean water to prevent damage when household bleach solution is used. Exam table paper must be changed between each client.
Wipe down exam and scale table surfaces, equipment and work surfaces at the end of each day with 1:100 dilution of household bleach solutions or an approved disinfectant after cleaning any visible soiling. Rinse with water to prevent damage when household bleach is used. Wall hooks should be placed in the examination room and clients should be instructed to hang their clothing rather than placing on floor or chair.
Clean visible blood and body fluid spills from all laboratory equipment, surfaces, cabinets and work surfaces with detergent and water. Then decontaminate with 1:10 dilution of household bleach solution or an approved disinfectant solution. Rinse with clean water to prevent damage when bleach is used.
Wipe down laboratory equipment and work surfaces at the end of each day with 1:100 dilution of household bleach solutions or an approved disinfectant after cleaning any visible soiling. Rinse with water to prevent damage when household bleach is used.
4. Toys-- Toys and other objects that are used by service providers in the assessment and evaluation of clients should be washed with soap and water and rinsed in a dilute bleach solution followed by a fresh water rinse between clients and at least daily. Toys mouthed by children should be washed and rinsed as specified above before any other child uses the toy. Any toy that cannot be easily cleaned (such as stuffed animals which cannot be machine washed) must not be shared among children in county health departments.
5. Decontamination of Spills- When cleaning spills the appropriate personal protective equipment (PPE) must be worn to prevent contamination. Wear gloves at a minimum and wear a mask if fluids may be splashed or aerosolized during cleanup.
a. Moist spills: Absorb the spill with disposable towels. Using a detergent solution, clean the spill site of all visible blood or body fluid. Wipe down with 1:10 dilution of household bleach solution or an approved disinfectant solution. Dispose of all materials used to decontaminate the spill as directed in Section 5.
b. Dry spills: If a surface or medical device is contaminated with dried blood or body fluid, remove all of it before disinfection. Following removal, wipe down with 1:10 dilution of household bleach solution or an approved disinfectant solution and rinse. 2011 Infection Prevention and Control Manual 34
Medical Equipment
1. Classification of Medical Equipment- For the purposes of this section, medical equipment is defined as critical, semicritical or noncritical.
a. Critical: Enters normally sterile tissue or the vascular system. All critical medical equipment should be purchased as sterile or be sterilized by steam under pressure. This category includes surgical instruments, urinary catheters, implants and needles.
b. Semicritical: Contacts mucous membranes or nonintact skin. These items must be free of all microorganisms, with the exception of high numbers of bacterial spores. Semicritical items generally require high-level disinfection. Most dental instruments, all instruments used for vaginal exams or procedures and respiratory equipment require high-level disinfection/sterilization. Thermometers, however, require only intermediate-level disinfection.
c. Noncritical: Comes into contact with intact skin. All noncritical medical equipment must be cleaned when visibly soiled. If contaminated with blood or body fluids, contaminated portions of the equipment must be thoroughly cleansed with a disinfectant solution. Examples of noncritical medical equipment include stethoscopes, otoscopes and blood pressure cuffs. These items require low-level disinfection.
2. Methods of Disinfection and Sterilization-
Used metal speculums are to be placed in soapy water immediately after use. The container must have a lid that seals. A sealable bucket or plastic tote may be used if kept in the clinic room. Open buckets are NOT to be utilized in the clinic room. Sterilization: A process by which there is complete elimination or destruction of all forms of microbial life. This can be accomplished by autoclaving. Prior to sterilization, the equipment must be thoroughly cleansed to remove all visible body fluids. After cleansing, place equipment in open metal autoclave pans. Autoclavable plastic pans are not effective. Equipment should be autoclaved for the time necessary to achieve and maintain a temperature of 121 C and a pressure of 15 psi for 30 minutes or longer. Typically, this will require at least one hour of autoclave time, depending on the type and size of the load. High-level disinfection: A process, which can be expected to destroy all microorganisms, with the exception of high numbers of bacterial spores. This can be accomplished by autoclaving.
Glutaraldehyde should not be used in the county health department. The county health department has the following choices: 2011 Infection Prevention and Control Manual 35
a. Items requiring sterilization may be autoclaved. County health department autoclaves are to be monitored using the guidelines listed in Laboratory Equipment #6: Autoclaves.
b. County health departments may choose to seek an agreement with a local hospital for autoclave services.
c. County health departments may choose to use disposable speculums in lieu of autoclaving. Intermediate-level disinfection: A process that inactivates Mycobacterium tuberculosis, vegetative bacteria, most viruses and most fungi, but does not necessarily kill bacterial spores. Smooth, hard surfaces can be disinfected with 1:10 household bleach solution or a commercial disinfectant with label claim for tuberculocidal activity. It is highly recommended that thermometer sheaths be used if disposable thermometers are not available. OSHA recommends discontinuing the use of glass mercury thermometers. http://www.osha.gov/SLTC/etools/hospital/hazards/mercury/mercury.html. Intermediate-level disinfection of glass thermometers can be achieved by soaking in 70%-90% isopropyl alcohol for at least 20 minutes. Do not mix thermometers used for oral and rectal use. Contaminated blood pressure cuffs, stethoscopes, and tourniquets may be disinfected with a 70% alcohol solution. Home visitors: All equipment that is taken into the home and used on clients must be properly disinfected after each use and before it is returned to the home visitor‘s vehicle. Equipment that has not been cleaned and disinfected after use may not be used on other clients. Low-level disinfection: A process which kills most bacteria, some viruses, and some fungi, but it cannot be relied on to kill resistant microorganisms such as tubercle bacilli or bacterial spores. Low-level disinfection can be accomplished by using a hospital disinfectant without label claim for tuberculocidal activity or a 1:100 dilution of household bleach.
Laboratory Equipment
Always follow manufacturer‘s instructions for routine cleaning and maintenance of equipment.
1. Blood Collection Equipment and Supplies-
Vacutainer System: Retractable vacutainer systems should be used for all venipunctures if possible. The entire retractable unit must be disposed of in an appropriate sharps container (see Section 5 for more on sharps disposal). Nonretractable vacutainer systems are never recommended. Retractable Butterfly and syringe units may be used on infants with strict attention to occupational health and safety.
Fingerstick Lancets: The OSDH requires the use of retractable lancet devices and single-use disposable lancets. 2011 Infection Prevention and Control Manual 36
2. Centrifuges-
Whole Blood: These centrifuges for spinning samples to obtain serum should be operated in an area away from clients and in a closed cabinet or enclosed area to prevent the general air distribution of aerosols should a tube of blood break. Every precaution should be taken to prevent breakage such as using a balance tube with an equal volume of water as the blood sample, across from the specimen.
Should a sample break in the centrifuge, heavy-duty polyurethane gloves must be worn and forceps must be used to remove particles of broken glass. Excess blood in the centrifuge should be removed prior to decontamination. The tube shields or trunnions should be removed and immersed in 1:10 dilution of household bleach for 10 minutes then rinsed with fresh water, dried, and the concave (aqua or black colored) cushion repositioned in the bottom of the shield or trunnion before returning to the centrifuge rotor head. The rotor head and bowl, if the centrifuge has one, should be wiped with 1:10 dilution of household bleach, and then with fresh water to remove the corrosive household bleach solution. Disinfectant wipes as described in Section 4, ―Guidelines for Cleaning, Disinfecting & Sterilizing‖ may be used to wipe the rotor head and bowl, followed by a clear water rinse.
3. Microscopes-
After contamination, the stage and controls may be wiped off with a suitable cleaning agent followed by a disinfectant or 1:100 dilution of household bleach and followed immediately with a fresh water rinse. The objective lens, eyepieces, lamp and condenser should be cleaned with lens cleanser and lens paper.
4. HemoCue Machine (Hemoglobin)-
Microcuvettes should be immediately disposed of in an appropriate sharps container following use. The HemoCue machine should be disinfected daily using 1:100 bleach solution. The slide out mechanism arm should be removed and disinfected weekly. At any time, visible blood should be immediately removed and followed by disinfection with a 1:10 bleach solution or an approved disinfectant, then wiped with fresh water.
5. Autoclaves-
Autoclaves must be monitored according to manufacturer‘s recommendations on a routine basis to ensure proper sterilization is being accomplished. While the use of heat sensitive dye markers is useful for monitoring individual loads, more sensitive biological monitoring must be performed and documented on a weekly basis. Biological monitoring can be accomplished using spore strips or vials that are placed as close to the center of the load as possible and subsequently incubated.
Correct sterilization of any item depends on several factors, mainly thorough cleaning of the item, proper preparation, packaging and positioning of the items in the load, and verification of the correct exposure time and temperature. Follow the manufacturer‘s recommendations to insure that steam reaches all surfaces of the items, and allows for effective steam removal to achieve proper drying. 2011 Infection Prevention and Control Manual 37
a. Arrange items so that they are not touching other items or the sides or door of the autoclave chamber. Do not overload or crowd items into the chamber.
b. If wrapped and non-wrapped items are being processed in the same load, use time/temperature guidelines for the wrapped items.
c. With each load: use heat sensitive chemical test strips that change color when a temperature of 121° C has been maintained for at least 12 minutes. Any items in a load where the test strip did not change color are NOT considered to be sterile.
d. Weekly or with each load if run less than weekly: perform biological testing using spore (Bacillus stearothermophilus) strips or vials per manufacturer‘s instructions. Interpret results per manufacturer‘s instructions. Results should be interpreted according to the instructions of the manufacturer. See Appendix 4-A for options of obtaining supplies and services for biologic monitoring.
e. Documentation: maintain a log book with the following criteria: (See Appendix 4-A for sample Autoclave Monitoring Log):
i. Each load: Record the date, type of items in the load, temperature, pressure, length of cycle, results of chemical indicators, results of biological indicators (when used), and signature of operator. To maintain a temperature of 121 C for 30 minutes or longer will typically require at least one hour of autoclave time, depending on the type and size of the load.
ii. At least once each week: Record the date quality control was performed, the basic content of the load (dental instruments, medical waste, etc.) date, temperature, pressure, length of cycle, signature of operator and the results of the biological monitoring of that load.
f. In the event an autoclave is determined to not be functioning appropriately to achieve sterilization (temperature of 121 and pressure of 15 psi not maintained for 30 minutes, or failure to pass heat sensitive or biologic monitoring), the materials must not be used and considered unsterile. The autoclave should be removed to a storage area until repaired or labeled as malfunctioning, and the administrative director notified.
g. If the facility rarely or irregularly uses the autoclave, consider establishing an agreement with a nearby hospital (or other licensed healthcare facility) to perform autoclave sterilization. Transport cleaned and wrapped (if appropriate) items to the facility in a closed container and transport autoclaved items back to the health department in a clean closed container. 2011 Infection Prevention and Control Manual 38
Records must be kept locally which verify the operating efficiency of autoclaves as monitored by heat sensitive and biologic monitoring methods.
Dental Instruments and Equipment
1. Dental Instruments- Any item that is used in the mouth and will be reused on another patient is to be cleaned, packaged, and heat-sterilized between uses using FDA-cleared sterilizers. Currently, OSDH dental clinics utilize steam-under-pressure sterilizers (autoclaves). If the item is heat-sensitive, it needs to be cleaned then sterilized by immersion in a liquid chemical cleared by FDA as a sterilant. Instruments need to be thoroughly cleaned prior to sterilization using cleaning equipment such as an ultrasonic. Before sterilization, inspect instruments for cleanliness, then wrap or place them in containers designed to maintain sterility during storage. Patient-care items are categorized as critical, semicritical, or noncritical, depending on the potential risk for infection associated with their intended use. Critical items such as surgical and other instruments that normally penetrate soft tissue or bone (i.e. forceps, scalpels, bone chisels, scalers and surgical burs) must be sterilized after each use or discarded. Semi-critical items touch mucous membranes or nonintact skin and have a lower risk of transmission; because the majority of semicritical items in dentistry are heat-tolerant, they also should be sterilized by using heat. If a semicritical item is heat-sensitive, it should, at a minimum, be processed with high-level disinfection. Noncritical patient-care items pose the least risk of transmission of infection, contacting only intact skin, which serves as an effective barrier to microorganisms. These should be cleaned with an EPA-registered hospital disinfectant with a tuberculocidal claim. Use of disposable barrier protection of these items might be a preferred alternative.
2. Monitoring- Monitoring of sterilization procedures should include a combination of process parameters, including mechanical, chemical, and biological. Monitor each load with mechanical (time, temperature, pressure) and chemical indicators. Biological indicators (i.e. spore tests) are the most accepted method for monitoring the sterilization process. Biological monitoring should be conducted weekly (or each clinic day if operations are conducted less than weekly). Mail-in monitoring services can be provided from private companies or dental schools. It is recommended that a monitoring log book be maintained.
In case of a positive spore test, remove the sterilizer from service and retest. If the repeat spore test is negative, put back into service. If the repeat spore test is positive, do not use the sterilizer until it has been inspected or repaired. Recall (to the extent possible) and reprocess all items processed since the last negative spore test. Before placing the sterilizer back into service, rechallenge the sterilizer with biological indicator tests in three consecutive empty chamber cycles after the cause of the failure has been determined and corrected. If instruments are to be stored after sterilization, they should be wrapped or bagged before sterilizing, using a suitable wrap material such as muslin, clear pouches, or paper as recommended by the manufacturer of the sterilizer. Following sterilization, the instruments should be stored in the sealed packages in a storage area with limited access, such as a closed cabinet. Event-related storage practices maintain that the contents of the package 2011 Infection Prevention and Control Manual 39
may be considered sterile unless the package is torn, wet, improperly stored or improperly or excessively handled, or is found to be contaminated. In these events, the contents of the package must be repackaged and resterilized.
3. Dental Handpieces- Dental handpieces, prophy angles and contra angles must be heat sterilized between clients with acceptable methods, which assure internal as well as external sterility. Disposable prophy angles are available and are to be discarded after one time use. The manufacturer‘s instructions must be followed for proper sterilization of handpieces, prophy angles and contra angles and for the use and maintenance of water lines and check valves. All dental units must have a check valve to prevent infective materials from being aspirated back into the water line. The first step before sterilization is to flush the handpiece with water by running it for 20 to 30 seconds, discharging the water into a sink or container. An ultrasonic cleaner should be used to remove any adherent material, but only if recommended by the handpiece manufacturer. Otherwise, the handpiece should be scrubbed thoroughly with a detergent and hot water. Many manufacturers recommend spraying a cleaner/lubricant into the assembled handpiece before and after sterilization. If in doubt as to whether a handpiece can be sterilized, contact the manufacturer.
4. Air/Water Syringes and Ultrasonic Scalers- Units should be flushed as described for handpieces. These attachments should be sterilized in the same manner as the handpieces, or in accordance with manufacturers‘ instructions. It is recommended that removable or disposable tips be used for these instruments and discarded after each client use.
5. Operatory Surfaces- Countertops and dental equipment surfaces such as light handles, x-ray unit heads, amalgamators, cabinet and drawer pulls, tray tables and chair switches are likely to become contaminated with potentially infectious materials during treatment procedures. These surfaces can be either covered or disinfected. Barrier protection can be provided by covering surfaces with plastic wrap, aluminum foil or impervious-backed absorbent paper. These protective coverings must be changed between clients and when contaminated.
If barriers are not used, surfaces should be cleaned and disinfected between patients by using a low-level EPA-registered hospital disinfectant with an HIV, HBV claim or a high-level tuberculocidal claim. Housekeeping surfaces, including floors, sinks, and related objects are not likely to be associated with the transmission of infection. However, the removal of visible soil and cleaning should be undertaken on a routine basis. Cleaners with germicidal activity may be used. Dental health care providers should wear gloves and other PPE to prevent occupational exposure to infectious agents and hazardous chemicals.
6. Impressions, Prostheses, Casts, Wax Rims, Jaw Relation Records- Items such as impressions, jaw relation records, casts, prosthetic restorations and devices, which have been in the client‘s mouth, should be properly disinfected prior to shipment to a dental laboratory. These items should be sprayed or immersed with an EPA-registered hospital intermediate-level disinfectant with a tuberculocidal claim when a laboratory case is sent off-site. Impressions must be rinsed to remove saliva, blood 2011 Infection Prevention and Control Manual 40
and debris and then disinfected. Impressions can be disinfected by immersion in a compatible disinfecting product. Since the compatibility of an impression material with a disinfectant varies, the impression material manufacturer‘s recommendations for proper disinfection should be followed. Disinfected impressions, which are sent to the dental laboratory, should be labeled as such in order to prevent duplication of the disinfection protocol.
7. Special Considerations- In dental radiology, the potential to cross-contaminate equipment and surfaces with blood or saliva is high if aseptic technique is not practiced. Gloves should be worn when taking radiographs and handling contaminated film packets. Other PPE should be used if spattering of blood or other body fluids is likely. Care should be taken to avoid contamination of the developing equipment by barriers or be cleaned and then disinfected after each patient use with an EPA-registered hospital disinfectant with of low or intermediate-level activity. Digital radiography instruments should be cleaned and ideally heat-sterilized or high-level disinfected between patients. Consult manufacturers regarding appropriate barrier and sterilization procedures for digital radiography sensors and computer components.
Extracted teeth that are being discarded are subject to the containerization provisions outlined by OSHA‘s bloodborne pathogens standard. OSHA considers extracted teeth to be potentially infectious material that should be disposed in medical waste containers. However, extracted teeth can be returned to patients on request, at which time provisions of the standard no longer apply.
Review and follow the Management Plan, Infection Prevention Practices and other content as applicable in the OSDH Infection Prevention and Control Manual.
Additional dental infection control information can be obtained from:
1. Guidelines for Infection Control in Dental Health-Care Settings 2003
MMWR – December 19, 2003/Vo. 52/No. RR-17
2. Organization for Safety and Asepsis Procedures (OSAP)
3. From Policy to Practice: OSAP‘s Guide to the Guidelines. OSAP,
Annapolis, 2004
4. Material Safety Data Sheets (MSDS)
Emergency Medical Equipment
1. Resuscitator Bags- Disposable resuscitator bags are recommended, and should be disposed of promptly after use. If non-disposable resuscitator equipment is used, resuscitator bags (i.e., adult and pediatric ambu bags) and pocket resuscitator masks must be cleaned following the manufacturer‘s instructions for cold sterilization.
2. Airways, Oxygen, Masks, and Tubing- All disposable equipment should be disposed of after use. Proper disposal of this equipment is covered in Section 5.
2011 Infection Prevention and Control Manual 41
3. Mannequins- Students should be told in advance that cardiopulmonary resuscitation (CPR) training sessions will involve ―close physical contact‖ with their fellow students.
Students should not actively participate in training sessions (hands-on training with mannequins) if they have dermatologic lesions on hands or in oral or circumoral areas, if they are known to be seropositive for hepatitis B surface antigen (HbsAg), if they have an upper respiratory tract infection, if they are known to be seropositive for Human Immunodefiency Virus (HIV), or if the student has reason to believe that he or she has been exposed to or is in the active stage of any infectious process.
All persons responsible for CPR training should be thoroughly familiar with hygienic concepts (i.e. thorough handwashing prior to mannequin contact, not eating during class to avoid contamination of mannequins with food particles, etc.) as well as the procedures for cleaning and maintaining mannequins and accessories (i.e., face shield). Mannequins should be inspected routinely for signs of physical deterioration, such as cracks or tears in plastic surfaces, which make thorough cleaning difficult or impossible. The clothes and hair of the mannequins should be washed periodically (i.e., monthly or whenever visibly soiled).
If more than one CPR mannequin is used in a particular training class, students should preferably be assigned contact with only one mannequin. Each student should use a disposable face shield specifically designed for use with mannequins. Following this recommendation will lessen the possible contamination of several mannequins by one individual and, therefore, limit possible exposure of other class members.
At the end of each class, the procedures listed below should be followed as soon as possible to avoid drying of contamination on mannequin surfaces:
a. Disassemble mannequin as directed by manufacturer.
b. As indicated, thoroughly wash all external and internal surfaces (also reusable protective face shields) with warm water, detergent and brushes.
c. Rinse all surfaces with fresh water.
d. Wet all surfaces with a 1:10 bleach dilution. This solution must be made fresh at each class and discarded after use.
e. Rinse with fresh water and immediately dry all external and internal surfaces; rinsing with alcohol will aid drying of internal surfaces, and this drying will prevent the survival and growth of bacterial or fungal pathogens.
Each time a different student uses the mannequin in a training class, the individual protective face shield, if used, should be changed. Between students or after the instructor demonstrates a procedure, the mannequin face and inside the mouth should be wiped vigorously with clean absorbent material (i.e., 4‘x4‖ gauze pad) wet with either the bleach solution described above or with 70% alcohol (isopropanol or ethanol). The surfaces should remain wet for at least 30 seconds before they are wiped dry with a second piece of clean absorbent material. Although alcohol is not a broad-spectrum bacteriological agent, in the context of vigorous cleaning with alcohol and absorbent material, little viable microbial contamination is likely after the cleaning procedure. 2011 Infection Prevention and Control Manual 42
2011 Infection Prevention and Control Manual 43
Management of Regulated Medical Waste
Regulated Medical Waste Disposal Plan
he following information shall serve as the Oklahoma State Department of Health Regulated Medical Waste Disposal Policy and Plan as required by the Oklahoma Department of Labor Public Employees Occupational Safety and Health Division. The Oklahoma State Department of Health will follow all applicable standards as written from the:
Oklahoma State Department of Labor Public Employees Occupational Safety and Health Division OS Title 40
Occupational Safety and Health Administration Standard 1910.1030 (d)
United States Department of Transportation Title 49 CFR 173.196-197; and, Oklahoma Department of Environmental Quality 27A 252:515-23 for the containment, transporting and disposal of all regulated medical waste.
Definitions
“Commercial regulated medical waste processing facility” means a facility operated as a business for profit that is designed and operated principally for the purpose of processing, including transfer of, regulated medical wastes generated by others. Such facilities shall include those engaged in the processing of regulated medical waste on mobile vehicles at a generator location. (DEQ 252:515-23-2)
“Commercial transporter “means an owner/operator of any vehicle transporting regulated medical waste generated by others. (DEQ 252:515-23-2)
“Contaminated Sharps” means any contaminated object that can penetrate the skin including, but not limited to, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires. (OSHA 1910.1030(b)
“DEQ” means the Oklahoma Department of Environmental Quality.
Section
5
T 2011 Infection Prevention and Control Manual 44
“Engineering Controls” means controls (i.e., sharps disposal containers, self sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace. (OSHA 1910.1030(b)
“Generator” means the owner/operator of any facility, institution, or business that produces regulated medical waste in any quantity. (DEQ 252:515-23-2)
"MSWLF" means Municipal Solid Waste Landfill; a publicly or privately owned landfill that is/or has received household waste. A MSWLF may also receive other types of non-hazardous solid wastes, such as non-hazardous sludge, NHIW, special waste, and construction/demolition waste.
“OSHA” means Occupational Safety and Health Administration.
"POTW" means Publicly Owned Treatment Works; a wastewater treatment system, as defined at 27A O.S. § 2-6-101, that is owned by a State or municipality for the treatment of municipal or industrial wastewaters.
“Regulated medical waste” means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials. (OSHA 1910.1030(b)
“DOT” means United State Department of Transportation
Examples of Regulated Medical Waste Within a County Health Department Live and attenuated vaccines that are being discarded. Blood and blood products-Discarded waste, human blood and blood products (i.e. serum, plasma) and materials as defined above as regulated medical waste. Sharps-Used sharps such as hypodermic needles, syringes, blood collection tubes, broken or unbroken glassware in contact with infectious items, including slides and cover slips. Items contaminated with blood or other human body fluids, which would drip freely or would release such materials if compressed. Items caked with dried blood or body fluids that are capable of releasing these materials, such as filter paper. Discarded feminine hygiene products used to absorb menstrual flow does not meet the definition of regulated waste. These items should be discarded in the regular waste receptacles that have been properly lined with a plastic bag. 2011 Infection Prevention and Control Manual 45
Discarded waste material contaminated with excretions, exudates, and secretions from clients with highly communicable diseases. Material, which, in the determination of the communicable disease nurse presents a significant danger of infection because it is contaminated with infectious agents.
Disposal of Regulated Medical Waste
Immediately, or as soon as possible after use, contaminated medical waste shall be placed in appropriate containers as follows:
1. Sharps- Must be placed in puncture-resistant, rigid containers immediately after use. Containers must be red in color, labeled with the universal biohazard symbol and closable. Containers must be located as close as possible to the use area, preferably within arm‘s reach of the user. Containers must not be placed on the floor, or in an area that is within the reach of small children. Containers must be considered full when between 1/2 to 2/3 filled and must be securely closed and stored for final disposal at that time. Under no circumstance should needles or lancets be recapped or otherwise manipulated by hand and must not require transport to another room for disposal in a sharps container.
2. Regulated medical waste other than sharps- must be placed in a fluid-resistant, closable container or bag colored red and/or labeled with the universal biohazard symbol. Plastic bags should be constructed of either polyethylene or polypropylene and should be impervious and tear resistant. These bags should be capable of being closed off, tied or sealed.
3. The disposal of the following is prohibited in a municipal solid waste landfill, a municipal solid waste receptacle or a municipal solid waste transfer station- any quantity of regulated medical waste as defined above under the OSHA 1910.1030(b) (definitions above) ―Regulated Medical Waste‖.
4. Liquid regulated medical wastes-may not be discharged into the collection system of a Publicly Owned Treatment Work (sewer) within the generating facility.
2011 Infection Prevention and Control Manual 46
Storage of Regulated Medical Waste in a County Health Department Prior to Final Disposal
Bagged regulated waste must be kept in secondary fluid-resistant, rigid containers (such as garbage cans or corrugated boxes) with closable tops while in the clinic setting. Reusable containers must be disinfected on a regularly scheduled basis and when visibly contaminated.
Sharps containers do not require a secondary container unless observed to be leaking or unless the integrity of the container has been compromised (indented, cracked, etc.).
At the end of each day or completion of clinic, regulated medical waste bags must be removed from secondary fluid-resistant container by appropriate health department personnel with annual bloodborne pathogen training and placed in box provided by the state contracted commercial transporter. These bags must be securely closed, placed in a box and locked in a storage room, which has limited access, this room must be labeled as biohazard. Contracted cleaning personnel are not to handle regulated medical waste and are to be made aware of the process and hazard.
Care must be taken to ensure that storage rooms are free of rodents and other disease vectors and are protected against precipitation.
Stored regulated medical waste must be maintained in a non-putrescent state, using refrigeration if necessary.
Options for Final Disposal of Regulated Medical Waste
OSDH must contract with a commercial regulated medical waste transportation and disposal company approved for operation by the Oklahoma Department of Environmental Quality- A contract for regulated medical waste transportation and disposal is available to county health departments. The company under contract provides containers for packaging and collection of full containers. An approved regulated medical waste tracking form must be received from the contracted commercial transporter every time waste is tr

Oklahoma State Department of Health
2011 Infection Prevention and Control Manual
Infection Prevention and Control Manual Committee Members
Susan Boyd, MS, RN
Kristy Bradley, DVM, MPH
Becky Coffman, MPH, RN, CIC
Sarah Flora, BSN, RN
Ginger James, BSN, RN, Chairperson
Phillip Lindsey, MD
Alan B. Loch, EC
Rocky McElvany, OSDH Safety Officer
Diana Pistole, MPH, MSN, ARNP
Debbie Purton, MPH, RN
Jana Winfree, DDS
RECORD OF CHANGES
OSDH INFECTION PREVENTION AND CONTROL MANUAL
(This plan is reviewed and updated annually)
Section
Date
MODIFIED: Section 1 Occupational Health Program-
Tuberculosis (TB) Skin Testing P. 1-4
Illness and Injury Reporting P. 8
January 2009
MODIFIED: Section 2 Management of Occupational Exposure to Bloodborne Pathogens-
Reporting an Exposure P. 12
January 2009
MODIFIED: Section 3 Infection Prevention Practices P. 19 - 30
NEW: Foot ware P.22
NEW: Respiratory Hygiene P. 23
NEW: Safe Injection Practices P. 23
January 2009
MODIFIED: Section 4 Guidelines for Cleaning, Disinfection and Sterilizing
New: Product Sterility and Shelf-life
P. 31
January 2009
MODIFIED: Section 6 TB Control Masks P. 51
Respiratory Isolation Room P. 51-52
January 2009
MODIFIED: Section 7 Infection Prevention and Control Guidelines for Clients Presenting with Rash Illnesses
P. 55
January 2009
UPDATED: Appendix 1A, 1C, 2K;
6A-F re-numbered to 5A-F
January 2009
UPDATED: Bibliography P. 125-127
January 2009
MODIFIED: Section 1, P. 2
Section 1, P. 6 & 7
January 2010
MODIFIED: Section 2, P. 17, HCV Testing
January 2010
UPDATED: Section 3 Infection Prevention
January 2010
MODIFIED: Section 6
January 2010
MODIFIED: Section 7
January 2010
MODIFIED: Appendix 1-D
January 2010
UPDATED: Infection Control Committee Members
January 2011
UPDATED: Section 1, P.1
January 2011 OSDH INFECTION PREVENTION AND CONTROL MANUAL
(This plan is reviewed and updated annually)
Section
Date
MODIFIED: Section 3, Standard Precautions: b, d, h, i
January 2011
UPDATED: Section 3, Transmission Based Precautions
January 2011
UPDATED: Section 3, Bioterrorism Agents
January 2011
MODIFIED: Section 4, Laboratory Equipment, Autoclaves
January 2011
MODIFIED: Section 4, Dental Instruments and Equipment
January 2011
UPDATED: Section 6
January 2011
UPDATED: Section 7
January 2011
UPDATED: Appendix 1-C, 1-F, 3-A, 5-C, 5-F
January 2011
UPDATED: Bibliography
January 2011
2011 Infection Prevention & Control Manual i
Table of Contents
Section 1: Occupational Health Program
Screening ......................................................................................................................... 1
Immunizations ................................................................................................................. 4
Immunocompromised Employees ................................................................................... 6
Health Education and Counseling ................................................................................. 6
Occupational Illness and Injury Reporting .................................................................... 7
Contract Agencies/Employees ......................................................................................... 8
Protection from Bloodborne Pathogens ......................................................................... 9
Employee Medical Records ............................................................................................. 9
Section 2: Management of Occupational Exposure to Bloodborne Pathogens
Treatment of Exposure Site ......................................................................................... 11
Reporting an Exposure ................................................................................................ 12
Testing ......................................................................................................................... 13
Exposure Evaluation for Counseling ........................................................................... 15
Source Client Evaluation ............................................................................................. 15
Management and Follow-up of Potential Exposure to HBV ....................................... 16
Management and Follow-up of Potential Exposure to HCV ....................................... 17
Management and Follow-up of Potential Exposure to HIV ........................................ 17
Section 3: Infection Prevention Practices
Standard Precautions ................................................................................................... 19
Transmission Based Precautions ................................................................................. 24
Infection Prevention and Control for Potential Bioterrorism Agents .......................... 25
Guidelines for the Work Setting .................................................................................. 27
Section 4:Guidelines for Cleaning, Disinfecting and Sterilizing
Product Sterility and Shelf-life .................................................................................... 31
Disinfectant Solutions.................................................................................................. 32
General Area Maintenance .......................................................................................... 32
Medical Equipment...................................................................................................... 34
Laboratory Equipment ................................................................................................. 35
Dental Instruments and Equipment ............................................................................. 38
Emergency Medical Equipment .................................................................................. 40
Section 5: Management of Regulated Medical Waste
Regulated Medical Waste Disposal Plan ..................................................................... 43
Definitions ................................................................................................................... 43
Examples of Regulated Medical Waste Within a County Health Department ............ 44
Disposal of Regulated Medical Waste......................................................................... 45
2011 Infection Prevention and Control Manual ii
Section 5: Management of Regulated Medical Waste
Storage of Regulated Medical Waste in a County Health Department Prior to Final Disposal ....................................................................................................................... 46
Options for Final Disposal of Regulated Medical Waste ............................................ 46
Transportation of Untreated Regulated Medical Waste by County Health Department Personnel .................................................................................................. 46
Section 6: Guidelines for the Prevention of Respiratory Transmitted Diseases in the Clinic Setting
Management of Client Waiting Areas .......................................................................... 49
Prevention of Tuberculosis Infection ........................................................................... 50
Tuberculosis Control Masks ........................................................................................ 50
Respiratory Isolation Room ......................................................................................... 51
Ultraviolet Irradiation .................................................................................................. 53
Sputum Specimen Collection ...................................................................................... 53
Written Tuberculosis Control Plan .............................................................................. 54
Pandemic Influenza ...................................................................................................... 54
Section 7: Infection Prevention and Control Guidelines for Clients Presenting with Rash Illnesses
Terminology ................................................................................................................ 56
Triage ........................................................................................................................... 56
Methods of Transmission .............................................................................................. 57
Management of Client Waiting Areas
Standard Precautions: Respiratory Hygiene/Cough Etiquette .................................... 57
Expanded Precautions: Droplet and Airborne ............................................................ 58
APPENDICES
Appendix 1-A - Tuberculosis Control Program ........................................................... 61
TB Mask Issuance Record ........................................................................................... 63
Appendix 1-B ................................................................................................................. 65
Annual Mask Fit Evaluation Form
Appendix 1-C ................................................................................................................. 67
Employees at Risk
Appendix 1-D ................................................................................................................. 69
Employee Training Record
Appendix 1-E ................................................................................................................. 71
Engineered Safety Devices Recommended Memo
Appendix 1-F ................................................................................................................. 73
Sequence For Donning Personal Protective Equipment
Appendix 2-A ................................................................................................................. 75
Post-Exposure Counseling Check Sheet, OSDH
2011 Infection Prevention and Control Manual iii
Appendix 2-B ................................................................................................................. 77
Occupational Exposure Report Form
Appendix 2-C ................................................................................................................. 81
Source Client Information
Appendix 2-D ................................................................................................................. 83
HIV/HBV Risk Factor Assessment: Population Groups and Risk Categories
Appendix 2-E ................................................................................................................. 85
Recommended Postexposure Prophylaxis Hepatitis B Virus
Appendix 2-F ................................................................................................................. 87
Information For Health Care Providers: Exposure To HbsAg Positive Or High Risk Client
Appendix 2-G ................................................................................................................. 89
HIV Postexposure Prophylaxis for Percutaneous Injuries
Appendix 2-H ................................................................................................................. 91
HIV Postexposure Prophylaxis for Mucous Membrane Exposures and Nonintact Skin Exposures
Appendix 2-I .................................................................................................................. 93
Referral Policy: Postexposure Prophylaxis Following Occupational Risk Exposures To HIV
Appendix 2-J .................................................................................................................. 95
Information For Health Care Providers: Exposure To HIV Positive Or High Risk Client
Appendix 2-K ................................................................................................................. 97
Exposure Flow Chart
Appendix 3-A ................................................................................................................. 99
Type and Duration of Precautions Needed for Selected Infections and Conditions
Appendix 3-B ............................................................................................................... 105
Respiratory Hygiene/Cough Etiquette
Appendix 4-A ............................................................................................................... 107
Sample Autoclave Monitoring Log
Appendix 5-A ............................................................................................................... 109
Isolation Room View
Appendix 5-B ............................................................................................................... 111
County Health Department Respiratory Isolation Room Inspection Report
Appendix 5-C ............................................................................................................... 113
Minimum Requirements for Tuberculosis Control
Appendix 5-D ............................................................................................................... 115
County Health Department Written TB Control Plan
2011 Infection Prevention and Control Manual iv
Appendix 5-E ............................................................................................................... 119
Negative Pressure Isolation Room Test Log
Appendix 5-F ............................................................................................................... 121
Infection Prevention Recommendations for Care of Patients With Pandemic Influenza
Bibliography .................................................................................................................. 123
Glossary Terms ............................................................................................................. 127
2011 Infection Prevention & Control Manual 1
Occupational Health Program
ealth care workers who provide direct services to or who work in the vicinity of persons who may be ill, are at increased risk for acquiring and transmitting infectious diseases. Direct service involves working face to face with clients or having ―hands on‖ contact with clients. Additionally, there are a number of infectious processes that present a possible threat to a health care worker that are vaccine preventable, or have specific indications for post exposure prophylaxis. Because the health and safety of Oklahoma State Department of Health (OSDH) employees is of utmost concern for the agency, an active Occupational Health Program is in place. The Occupational Health Program has two important goals:
To protect clients and employees by Facilitating disease detection and treatment Eliminating or minimizing occupational exposure to bloodborne pathogens Managing exposures to communicable disease Promoting a safe environment Promoting employee education
To comply with government regulations Occupational Safety and Health Administration (OSHA) Oklahoma Department of Labor (ODOL) Oklahoma Public Health Code
Infection control and safety are both important parts of any Occupational Health Program. Infection control standards serve to provide a safer environment to employees by facilitating prevention, detection and control of communicable diseases within the work setting.
Screening
Tuberculosis (TB)
Employee screening for M. tuberculosis infection status will follow the MMWR December 30, 2005 Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005.
Section
1
H 2011 Infection Prevention and Control Manual 2
1. Baseline evaluation for M. tuberculosis infection- Documentation of baseline M. tuberculosis infection status is required for all new employees and directly observed therapy (DOT) providers at county health departments and for all new central office staff with direct client contact. Baseline evaluation requires either 1) tuberculin skin testing using the Mantoux method or, 2) specific documentation of having a prior positive tuberculin skin test (with date applied and measurement in millimeters of induration). Specific recommendations for baseline evaluation are as follows:
Perform ―two-step‖ baseline testing on individuals with:
a) no previous TST result
b) single previous negative TST result (documented or not) >12 months before new employment
c) previous undocumented positive TST result
d) history of BCG vaccination
Perform single TST baseline testing on individuals with:
a) two or more documented negative TSTs (but most recent TST
>12 months before new employment)
b) single previous documented negative TST result ≤ 12 months
before new employment)
Note: Both the single-step and the two-step TST are to be performed in accordance with the MMWR December 30, 2005 Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005.
Do not perform baseline or subsequent TST on individuals with:
a) previous documented positive TST result
b) documented completion of treatment for latent TB infection or TB disease
c) documented ulceronecrotic reaction to a prior TST or documented true anaphylactic reaction to prior TST
Note: in individuals a, b or c (immediately above) a symptom screen is all that is required for baseline or subsequent TB screening.
2. Follow-up (serial) evaluation for M. tuberculosis infection- Tuberculin skin testing must be performed annually for all county health department employees, DOT providers and for all central office employees with direct client contact, unless a previous positive tuberculin skin test has been documented or a contraindication to TST exists. Employees who consistently work with active TB cases should be tested every 6 months. A single-step TST is all that is ever required. Two-step testing SHOULD NOT be performed for follow-up testing. If an employee develops symptoms suggestive of tuberculosis, they should be referred to their county health department for evaluation.
3. Follow-up for an Employee or DOT Provider with a Positive TST- An employee with an initially positive TST should be referred to a private physician or the county health department for a chest x-ray and medical evaluation. An Incident Report ODH Form 33 should be completed and forwarded to the Safety Officer. The ODH Form 33 can be accessed through Public Folders under Administrative Policy 6-24 or through the Safety 2011 Infection Prevention and Control Manual 3
Program. The employee should be educated regarding the signs and symptoms of TB, and instructed to notify his/her supervisor if symptoms suspicious of TB occur. An evaluation should then be performed to rule out active TB.
An employee with a history of a positive tuberculin skin test (TST) and a negative chest x-ray (whether they have taken preventive therapy or not) should not have additional chest x-rays unless the employee develops signs and symptoms suggestive of TB. If the employee is unable to obtain a copy of his/her negative chest x-ray report, a chest x-ray should be performed as a baseline and submitted with TB Core Health History, ODH Form 245, to the OSDH TB Medical Consultant for evaluation. TB forms are located in the TB Manual. The employee may choose to be evaluated by his/her private physician. A copy of the negative chest x-ray interpretation should be kept as part of the Employee Medical Record. Annually, the employee should be questioned regarding signs and symptoms of illness using Tuberculosis Questionnaire, ODH Form 247.
An employee with a documented positive tuberculin skin test (TST) and history of an abnormal chest x-ray and/or report should have TB Core Health History, ODH Form 245, and other portions of the Adult Health Record (as designated by current protocol), opened and be evaluated by the OSDH TB Medical Consultant or a private physician. The OSDH TB Medical Consultant will determine the need for a repeat chest x-ray. These records must be maintained as part of the Employee Health Record.
4. TB Mask Fitting- All employees and DOT providers working with active, suspected or potential TB clients must wear disposable particulate respirator (DPR) masks. Different DPRs are indicated for employees and for clients and are not interchangeable. Employees must be fitted for the appropriate size of DPR, which has a National Institute for Occupational Safety and Health (NIOSH) rating of N95 or greater. The DPR mask used must be capable of forming a seal around the nose and mouth area of the employee‘s face. This is documented on TB Mask Issuance Record, ODH Form 809, which is located in Appendix 1-A and is to be kept as part of the Employee Medical Record. The form does not require a physician signature unless the employee has a medical condition that requires physician evaluation or has difficulty with the test and is referred to a physician for evaluation (OSHA 1910.134.App A). Using the Annual Mask Fit Evaluation Form, ODH Form 285, the employee should be evaluated to determine if there has been gain or loss of 10% or more of body weight, use of dentures, beard /mustache or any facial surgery.
If any of the five questions are answered YES, the employee must be refit for an appropriately fitting DPR. The employee must not be allowed to provide services to a TB client until they have been refit and have an appropriately fitting disposable particulate respirator on hand to use.
If the employee provides information in the comments portion of the form that indicate a problem with the mask that was previously issued to them, the District Nurse Manager (DNM) must address those issues or concerns to a satisfactory resolution before the nurse will be allowed to provide service to a TB client. 2011 Infection Prevention and Control Manual 4
If all answers to the questions 1-5 are NO, it will be presumed that the DPR the employee is currently using is a proper fitting respirator and no further mask fit testing will be required at that time.
If the employee does not indicate any problems or concern with the mask in the comment area, it will be presumed the disposable respirator they were previously issued is still an appropriate fitting DPR and repeat mask fit testing will not be required at that time.
In signing the form, it is understood that the DNM/designee takes responsibility to see that the employee who has indicated the need to have repeat mask fit testing performed, will be refitted immediately. If re-fitting is not available immediately, the signature indicates it is understood that the employee is not to provide services to a TB client until they are refit tested and have an appropriately fitting disposable particulate respirator on hand for use.
5. TB Contact- If an employee has unprotected contact to an active, untreated TB case, a tuberculin skin test (TST) should be administered immediately (unless tested within the previous month) and repeated 3 months after the exposure. If the employee is a previous TST reactor, they should be questioned regarding signs and symptoms of illness using Tuberculosis Questionnaire, ODH Form 247 rather than receiving a TST. Should the employee become symptomatic, they should be evaluated by collecting three (3) sputum specimens for acid-fast bacilli (AFB) smear and culture and obtaining a PA and lateral chest x-ray. Submit the chest x-rays with a TB Core Health History, ODH Form 245, to the OSDH TB Medical Consultant for interpretation. An Incident Report, ODH Form 33, must also be completed and routed appropriately.
Immunizations
Guidelines for Vaccination of Employees
The following vaccines are required for employees whose job duties place them at risk, and for those who cannot provide proof of adequate previous vaccination or immunity as documented by medical record or laboratory testing. Vaccines are to be made available without charge to all employees deemed to be at risk. These guidelines are also applicable for contract, seasonal or temporary employees. Any employee not in compliance with these guidelines should be placed in only low risk areas (i.e., away from direct client contact).
1. Rubella- Proof of immunity or one dose of a Rubella containing vaccination (MR or MMR vaccine) is required for all county health department personnel and all Central Office personnel who have direct client contact. Birth before 1957 is considered acceptable evidence of immunity to Rubella except for those female employees who can become pregnant. Pregnancy is a contraindication to vaccinating with Rubella.
2. Rubeola- Required for all county health department personnel and all Central Office personnel who have direct client contact, were born in 1957 or after, and who do not have one of the following: Documentation of physician-diagnosed measles disease; written documentation of two doses of measles-containing vaccine (MMR is the preferred vaccine); or, a blood test showing measles immunity. Pregnancy is a contraindication to vaccination against rubeola. 2011 Infection Prevention and Control Manual 5
3. Mumps- Proof of immunity or one dose of Mumps vaccine (MMR vaccine) is required for all county health department personnel and all Central Office personnel who have direct client contact. Birth before 1957 is considered acceptable evidence of immunity to Mumps. Pregnancy is a contraindication to mumps vaccine.
4. Hepatitis B- Employees at risk for Hepatitis B infection include those who are ‗reasonably anticipated‘ to have routine blood exposures in the normal course of their work. Appendix 1-C details the potential types of exposures and personnel who may be at risk of these exposures. Employees at greatest risk include:
a. Those with daily exposure to blood or blood products by venipuncture.
b. Those exposed to blood or blood products in high-risk areas (i.e., STD clinics).
c. Laboratory and dental personnel with frequent contact to blood, blood products or other body fluids.
Within 10 days of employment, employees at risk must document their hepatitis B vaccination status on page 3 of ODH Form No. 807 (Occupational Health Record, Employee Screening Record, and Hepatitis B Vaccination Status). This form is available to central office employees through the Occupational Health Nurse. County health department employees should receive this form as a part of the New Employee Packet or through their local District Nurse Manager. Note that training on the risk of infection with bloodborne pathogens must have been provided prior to the date of the employee‘s declination. Employees who provide documentation of previous infection with hepatitis B (anti-HBc positive) have no need for vaccine.
Documentation of an anti-HBs titer that is greater than or equal to 10mIU/ml will be accepted as proof of immunity to Hepatitis B. Nonresponders to a previous complete Hepatitis B vaccination series should receive a second complete Hepatitis B vaccine series. Following the second series, those who continue to be nonresponders should be considered susceptible to Hepatitis B viral (HBV) infection, and should be counseled regarding precautions to prevent HBV infection and the need to obtain Hepatitis B immune globulin (HBIG) prophylaxis for any known exposure to hepatitis B surface antigen (HbsAg) positive blood. Testing for vaccine response is not available through OSDH Public Health Lab. County health department Administrators may choose to contract with a lab of their choice for (anti-HBs) vaccine response testing for their local employees for whom they administer the hepatitis B vaccinations, though this testing is not required. In the event that an exposure should occur, the employee may be tested at that time if no documentation exist confirming adequate titer.
5. Varicella (chickenpox)- All county health department personnel and Central Office personnel with client contact should be questioned regarding history of chickenpox. Those persons who do not have a reliable history of chickenpox disease, serologic evidence of disease, one dose of varicella vaccine on or after the first birthday prior to 2011 Infection Prevention and Control Manual 6
the 13th birthday, or two doses of varicella vaccine separated by at least 28 days on or after the 13th birthday, should be vaccinated against Varicella.
The following vaccinations are strongly recommended for employees:
1. A. Tetanus-Diphtheria- After primary immunization, a tetanus-diphtheria booster
is recommended for all persons every 10 years. Primary immunization of adults consists of three doses of adult tetanus-diphtheria toxoid (TD); 4-5 weeks should separate the first and second doses, with the third dose given 6-12 months after the second.
1. B. Tetanus-Diphtheria and Pertussis (Tdap) Adacel-A single dose of Adacel vaccine may be used to replace a single dose of Td for booster immunization against tetanus, diphtheria and pertussis in adults 19 through 64 years of age. Tdap vaccination is recommended for adults who have close contact with infants.
For female employees who are pregnant, the ACIP recommends vaccination with Td during pregnancy.
2. Influenza- Influenza vaccination is the most effective method for preventing the infection and transmission of influenza. The ACIP recommends influenza vaccination amongst health-care personnel (HCP) to be one of the measures of a patient and community safety quality program. All health-care personnel are encouraged to receive annual vaccination against influenza.
3. Rabies- Rabies vaccine may be indicated for persons in high-risk groups, such as veterinarians, animal handlers and certain laboratory workers.
Immunocompromised Employees
Immunocompromised individuals may be susceptible to infections of various types. Due to their weakened or depressed immune systems, they may have a more severe course of infection. Individuals may be immunocompromised for various reasons such as chemotherapy or irradiation for a neoplasm, medication use after an organ transplant to prevent rejection, long-term steroid therapy or Human Immunodeficiency Virus (HIV) infection.
Employees known to be immunocompromised should be placed in a location that will minimize potential for exposure to infectious disease. In addition, it is important to ensure that they are protected as much as possible through immunization. However, no immunizations should be administered to an immunocompromised employee without a direct order from the employee‘s physician.
Health Education and Counseling
Annual Bloodborne Pathogen Training
The OSDH must ensure that all employees with potential for occupational exposure to blood or body fluids participate in training programs. This training is essential to 2011 Infection Prevention and Control Manual 7
OSHA compliance. The programs must be provided at no cost to the employee, during work hours, with material appropriate to the education, literacy and language of the employee. It is the employees‘ supervisor‘s responsibility to see that the training is provided within 10 days of employment and within one year from the initial previous training. All employees must receive training annually, with additional training if changes are made that affect the employee‘s occupational exposure. The training is to be documented on the OSHA training record, ODH form N47, which is located in public folders. The completed sign in sheet is to be faxed 405.271.3539 to Training, Education & Development Division of OSDH for filing.
To locate ODH Form N47 on Public Folders, click on Safety Program; Forms; ODH Form N47
The Employee Training Record (Appendix 1-D) is optional to be completed by the employee‘s supervisor or designee. The OSHA Training Record (N47), which documents the names and titles of attendees, the date of the training, course content, and the name of the trainer must be kept for a period of 3 years.
Annual TB Training and Counseling
All OSDH employees requiring annual TB skin testing will receive annual TB training regarding TB infection, transmission and control provided by their division. A review of TB epidemiology for the county with application to the county health department will occur. The training will include: a review of county health department TB control procedures, TB suspect client handling, respiratory isolation use and TB mask usage requirements for employees, clients and family members. Training in any new or revised TB control procedures will be given.
Counseling regarding TB risk factors and TB infection shall be available on a one-on-one basis to any county health department employee from the TB nurse or the DNM. This shall include specific job-related risks. Known immunocompromised employees shall be counseled by the DNM regarding the risk of exposure to active TB.
Occupational Illness and Injury Reporting
Incident Reporting
To locate ODH Form 33 on Public Folders, click Safety; Forms; ODH Form 33
An Incident Report, ODH Form 33, should be initiated and faxed to the Safety Officer at 405-271-3933 as soon as possible, and no later than 72 hours following the occurrence, completed with all required information and signatures. This form can be accessed on Public Folders. The form can be completed electronically, printed and signed; or you may print the form and complete hand written, and signed. This official report is necessary to file for worker‘s compensation benefits for post exposure follow-up. After all required signatures and information are obtained a copy of the completed and signed incident report must be faxed to the Safety Office at 405-271-3933. The original completed Incident Report will be maintained at the County Health Department or Service Area of the occurrence. 2011 Infection Prevention and Control Manual 8
Authorization for Medical Attention, ODH form 10M, should be completed by the supervisor and provided to the employee at the time that it becomes evident that medical evaluation or treatment is required following a work related injury or illness. This form is available through the OSDH Safety Office at 405-271-4479.
The Oklahoma Department of Labor (ODOL) requires each public sector employer to maintain and post a record of certain injuries and illnesses. The OSDH Agency Workers’ Compensation Office maintains these records and distributes a Site OK Form 300 – Log of Work-Related Injuries and Illnesses to each OSDH satellite location and County Health Department annually, prior to February 1st of each year. The OK Form 300 A – Summary of Work-Related Injuries and Illnesses shall be posted during the period of February 1 through April 30 at the central OSDH Office First Floor Safety Bulletin Board, and at each individual OSDH satellite location and County Health Department Safety Bulletin Boards. The OK Form 300 and OK Form 300 A shall be retained in the central OSDH Office, individual satellite locations and County Health Departments for five (5) years. The original OK Form 300 and OK Form 300 A are kept in the central OSDH Human Resources, Benefits/Workers‘ Compensation office. OSHA and DOL require the preservation and maintenance of employee medical and exposure records for at least the duration of employment plus thirty (30) years.
Contract Agencies/Employees
Contract Agencies
When a contract agency is utilized to provide services at a county health department or central office location and the service offered places the contract employee at risk of exposure to bloodborne pathogens, the contract agency must provide documentation of training and hepatitis B vaccination for those employees as required by the OSHA standard on bloodborne pathogens.
Contracts with agencies providing services which place their employees at risk where such services are offered directly by the contracting agency (i.e., community-based organizations) must include a statement of intent to meet the requirements of the OSHA standard on bloodborne pathogens.
Contract Employees
In the event an individual is contracted (not through an agency), the individual must document:
1. having received training on bloodborne pathogens.
2. having been vaccinated against hepatitis B, immunity to hepatitis B or refusal to take hepatitis B vaccine.
Alternately, the county health department may offer such training and vaccination before the employee begins work. 2011 Infection Prevention and Control Manual 9
Post-exposure Treatment for Contract Employees
Follow-up and treatment for contract employees who sustain an occupational risk exposure at an OSDH facility is the responsibility of the contracting agency or contract employee. However, the county health department administrator or central office service chief should ensure that follow-up is being provided. Student nurses are not considered contract employees; the responsibility is between the school and the student for testing.
*Follow-up and treatment for nursing students who sustain an occupational risk exposure at an OSDH facility is the responsibility of the student and/or their school of nursing.
Protection from Bloodborne Pathogens
Personal Protective Equipment
To locate the Job Specific PPE list see Safety Program; Safety Manual; Job Specific Protective Equipment
OSHA standards require employers to provide protective equipment (PPE) when employees are at risk of exposure to bloodborne pathogens, but also when there is risk to encounter hazards that are capable of causing injury by absorption, inhalation or physical contact. This equipment includes protection for eyes, face, head and extremities, protective clothing, respiratory devices and protective shields and barriers. A lab coat/jacket is required for all client contact but is not considered PPE. The equipment is to be maintained in a sanitary, reliable condition.
Safety Devices
To locate the Retractable Safety Syringe Policy on Public Folders, click on Safety Program; Safety Manual; Retractable Safety Syringes
On December 1, 2004, OSHA published revisions to the Bloodborne Pathogens Standard in the Federal Register. At the mandate of the ODOL, OSDH Safety Committee has worked to meet these requirements, by evaluating and implementing appropriate engineering controls and work practices to prevent or minimize exposures to bloodborne pathogens. The specific engineering controls and work practice controls used are outlined in the Exposure Control Plan. An agency wide memorandum was processed, which has become the directive for safety device use by OSDH employees. This policy is located on Public Folders and is in Appendix 1-E.
Employee Medical Records
Employee medical records must be kept in a locked, secured cabinet, separate from all other records. Employee medical records are kept by the agency for 30 years following termination of the employee. The employee has a right to access his/her medical record upon request. Employee medical records are to be maintained in accordance with the Employee Medical Records Policy located under Administrative Policy Number 6-32. 2011 Infection Prevention and Control Manual 10
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Management of Occupational Exposure to Bloodborne Pathogens
n occupational exposure incident refers to a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood/ bloodborne pathogens or other potentially infectious materials that results from the performance of an employee‘s job duties. Potentially infectious body fluids include blood, semen, vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid and amniotic fluid. Feces, nasal secretions, saliva, sputum, sweat, tears, urine and vomitus are not considered potentially infectious unless they contain visible blood.
Percutaneous and non-intact skin exposures are defined as the introduction of blood or other potentially infectious body fluids directly through the skin (i.e., puncture or cut by sharp contaminated objects or introduction of blood or potentially infectious body fluids on areas where skin integrity is compromised).
Mucous membrane exposures are defined as the introduction of blood or potentially infectious body fluids directly onto the mucous membranes of the eyes, nose or mouth.
Management Plan (See Appendix 2-K)
Treatment of Exposure Site
Employees who sustain an occupational exposure (as defined above) should immediately address the exposure site.
1. Wounds and skin sites that have been in contact with blood or body fluids should be washed with soap and water.
2. Mucous membranes that have been in contact with blood or body fluids should be flushed using an eyewash station. Please refer to Section 3 for Eyewash Station Requirements.
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No evidence exists that using antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk of bloodborne pathogen transmission; however, the use of antiseptics is not contraindicated. The application of caustic agents (i.e., bleach) or the injection of antiseptics or disinfectants into the wound is not recommended.
Reporting an Exposure
County health department employees who sustain an occupational exposure should immediately report to the DNM, Coordinating Nurse or Lead Nurse. Central office staff who sustains an occupational exposure should immediately call the Occupational Health Nurse at (405) 271-5180. If the source client is present in the clinic, the client should be requested to remain in clinic until plans for follow-up have been quickly assessed. This will facilitate obtaining additional blood samples on the source client if needed.
A Post-exposure Counseling Check Sheet may be used to assist the person responsible for managing the exposure. This form is located in Appendix 2-A.
To locate ODH Form 33 on Public Folders, click Safety; Forms; ODH Form 33
An Incident Report, ODH Form 33, should be initiated and faxed to the Safety Officer at 405-271-3933 as soon as possible, and no later than 72 hours following the occurrence. This form can be accessed on Public Folders. There are two versions of the form available, one to be electronically completed, and one for manual completion. Either are appropriate in the case of an occupational exposure. This official report is necessary to file for worker‘s compensation benefits for post exposure follow-up. After all required signatures are obtained, the completed report should be faxed to the Safety Officer at 405-271-3933. The original is maintained at the County Health Department.
The employee‘s supervisor should provide the employee with an Authorization For Medical Attention, ODH Form 10M, at the time that it becomes evident that further medical evaluation is required.
The Occupational Exposure Report, ODH Form 811, should be completed and is to be kept as part of the Employee Medical Record. This form is available through the local DNM or the Occupational Health Nurse.
When an employee has sustained an exposure, consultation for management of the exposure is available from the agency Occupational Health Nurse, 405-271-5180.
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Testing
1. Testing- Testing of the exposed employee and source client for HIV, Hepatitis C. ALTand/or Hepatitis B is indicated. Regardless of the potential risk, any exposed employee has the right to request or decline testing. If an employee declines testing after an exposure, that needs to be documented on the ODH 811, Exposure Report and on the Incident Report. The Oklahoma Public Health and Safety Code, 63 O.S., 1992, Section 1-502.3 allows for testing available blood of the source client and release of the results without the client‘s consent when a written report of an exposure has been made. However, the source client should be informed of the intent to test and the rationale for testing. Source Client Information located in Appendix 2-C, should be reviewed with the source client during the postexposure counseling session.
In the event that source blood has not been drawn and the source client refuses to allow blood to be drawn, contact the Occupational Health Nurse at (405) 271-5180 for consult. If indicated, a court order can be obtained to allow blood to be drawn. However, before going to that extent, a careful review of the circumstances would need to be made by the Occupational Health Nurse, OSDH State Health Officer or designee and OSDH Legal Services.
a. Test Requisitions-
OSDH currently has a contract in place with a contract lab for Hepatitis B & Hepatitis C testing. The lab requisition must be marked identifying the specimens as “Occupational Health” when submitting the specimens. The ICD 9 code: V15.85 is the code for exposure to potentially hazardous body fluids. This code must be added to the lab requisition when submitting ―Occupational Health‖ exposure lab specimens. A separate Specimen Referral Log should be kept in a folder in the same locked file cabinet as the Employee Medical Records. Only the persons with authorized access to the Employee Medical Records should have access to and document on this form.
Human immunodeficiency virus (HIV) testing of both the exposed employee and the source client is performed by the OSDH Public Health Laboratory Service. Do not enter the employee information into the Public Health Oklahoma Client Information System (PHOCIS) computer program. A manual copy of the Public Health Laboratory (PHL) requisition must be completed for the employee specimen. All PHL requisitions related to occupational exposure must indicate “Occupational Health”. Send HIV test specimens with appropriate ODH requisition forms to:
Oklahoma State Department of Health
Public Health Laboratory
1000 N.E. 10
PO Box 24106
Oklahoma City, Ok 73117
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b. Blood Specimen Collection-
Hepatitis- One full serum separator tube per person is sufficient to complete testing for both Hepatitis B and Hepatitis C. The blood should be spun down and the tube should be clearly labeled with the donor name, date of specimen collection, name of test requested and clinic site number. Specimens should be carefully packaged to prevent leakage or breaking. The outer package must be labeled as biohazardous.
Hepatitis B and Hepatitis C lab specimens for employees and source clients associated with an occupational exposure are to be sent to the contract lab for processing. The exposure source should be tested for the surface antigen (HbsAg) and the employee should be tested for surface antibodies (HbsAb).
HIV- One full serum separator tube should be drawn for HIV testing. The blood should be spun down and the tube should be clearly labeled with the donor‘s name, date of specimen collection, name of test requested and clinic site number. Specimens should be carefully packaged to prevent leakage or breaking. The outer package must be labeled as biohazardous.
A manual copy of the requisition should be copied from the Public Health Laboratory Resource Manual for use on occupational exposures. The requisition for such test should not be printed from the computer in order to protect the employee’s confidentiality.
Before submitting the specimen, the lab requisition must be marked as an Occupational Health test at the top of the page on the right-hand corner. This alerts the lab personnel to the reason for the manual requisition. CompSource should be listed in the insurance section of the form to ensure proper billing to worker‘s comp.
c. Release of Test Results-
Health Insurance Portability and Accountability Act of 1996 (―HIPAA‖) apply to all parties in an exposure testing situation. Only those persons directly involved in the exposure incident are to be informed of test results. This normally would include only the source client, the exposed employee and whomever the employee designates such as the DNM or designee.
Source client test results may be released to the exposed employee, the DNM, designee and Occupational Health Nurse without the expressed written consent of the source client per Oklahoma state law requiring documentation of occupational exposures.
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Exposed employee test results are not to be released to any person or facility, other than the Occupational Health Nurse, DNM or designee without the expressed written consent of the employee (OSHA: CFR 1910.1030 (h.) Medical Records). It is not necessary for source client name, code number or test results to be released on worker's compensation claims in order for the claim to be processed. Claims related to seroconversion of the exposed employee would necessitate release of source client test results, but not source client name.
d. Filing of test results-
The exposed employee‘s test results are to be kept as part of the Employee Medical Record. The source client‘s test results are not to be filed in the Employee Medical Record. A separate folder, which contains source client test results, should be kept in the same locked cabinet as the Employee Medical Record.
Exposure Evaluation for Counseling
In order to counsel the exposed employee regarding the risk of contracting a communicable disease following the exposure, the DNM or designee, should evaluate the exposure based on the type of body substance involved and the route and severity of the exposure.
Percutaneous injuries- Injuries resulting from solid needles or superficial injuries are considered LESS SEVERE. Injuries resulting from large bore hollow needles, deep punctures, and visible blood on the device or a needle used in a client‘s artery or vein is considered MORE SEVERE.
Mucous membrane exposures- Consider volume of fluid involved. A few drops poses LESS RISK than a major blood splash.
Skin exposures- Follow-up is indicated only if there is evidence of compromised skin integrity (i.e. dermatitis, abrasion, or open wound).
Human bites- Follow-up should be provided to both the person bitten and the person who inflicted the bite when the bite results in a blood exposure.
Source Client Evaluation
The person whose blood or body fluid is the source of an occupational exposure should be evaluated for HIV, hepatitis C (HCV), and/or hepatitis B (HBV) infection as indicated. If the HBV, HCV, and/or HIV infection status of the source is unknown, the source should be informed of the incident and tested for serologic evidence of infection.
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Tests to be requested for the source client may include: HbsAg: Hepatitis B surface antigen anti-HCV: Hepatitis C antibody HIV-EIA: Human Immunodeficiency virus antibody
If the exposure source is unknown or cannot be tested, information about where and under what circumstances the exposure occurred should be assessed for likelihood of transmission of HIV. Testing of needles or other sharp instruments implicated in an exposure is not recommended.
Information to consider when evaluating an exposure source would include previously documented laboratory tests, presence of clinical symptoms of HIV and history of recent (within previous three months) possible exposure to HBV, HCV, and HIV (i.e., injection drug use, or sexual contact with a known positive partner). Appendix 2-D includes information to assist in assessing risk factors.
Management and Follow-up of Potential Exposure to HBV
Following an exposure, the Hepatitis B vaccination status and the vaccine response status (if known) of the exposed person should be reviewed. If the exposed employee has had a previous titer (anti-HBs) with a response equal to or greater than 10 mIU/mL then there is no need to test for Hepatitis B surface antigen. If the vaccination and antibody response status of the exposed employee is unknown then a (HbsAb) Hepatitis B surface antibody (qualitative) test needs to be done at the time of exposure. A summary of Hepatitis B prophylaxis recommendations is located in Appendix 2-E. Adequate antibody response following Hepatitis B vaccination is defined as an anti-HBs response of equal to or greater than 10 mIU/mL.
A ―qualitative‖ Hepatitis B Surface Antibody Test is acceptable if the processing lab can verify that an ―immune‖ response represents an antibody response of 10 mIU/ml or greater.
The vaccinated employee is referred to as a known responder (anti-HBs equal to or greater than 10 mIU/mL), non-responder (anti-HBs less than 10 mIU/mL after two complete series of Hepatitis B vaccine), or response unknown (anti-HBs result unknown).
When Hepatitis B Immune Globulin (HBIG) is indicated for a non-responder or employee with an unknown response, the county health department should determine the most expedient resource to secure it. The county health department may consult with the Occupational Health Nurse to determine the need and possible resources. HBIG should be administered as soon as possible after exposure (preferably within 24 hours), but may be administered up to 7 days post exposure.
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In the case of an exposed employee who is a known responder, testing the source for HbsAg is not necessary.
Appendix 2-F includes information to share with the employee who is exposed to HbsAg positive or high-risk clients.
Management and Follow-up of Potential Exposure to HCV
Currently, no data exists which shows that either Immune Globulin (IG) or use of antiviral agents is effective in preventing HCV. Rather, postexposure management for persons potentially exposed to hepatitis C virus is aimed at achieving early identification of chronic disease and, if present, referral for evaluation of treatment options.
Testing for the employee exposed to an HCV-positive source should include: Initial baseline anti-HCV and ALT 6 months post-exposure anti-HCV and ALT
Confirmatory testing should be performed on all positive anti-HCV results.
Management and Follow-up of Potential Exposure to HIV
The county health department employee who sustains an exposure should be evaluated immediately by the DNM or designee and blood should be collected for baseline HIV testing. The employee‘s baseline blood sample may be tested immediately or held for up to 90 days. The employee has the right to refuse HIV testing and follow-up.
If the source person is seronegative for HIV and denies symptoms of acute viral illness (fever, rash, myalgia, fatigue, malaise or lymphadenopathy), baseline testing or further HIV follow-up of the exposed employee is not necessary, but should be made available if the exposed person is concerned.
Recommended follow-up for potential exposure to HIV is based on current Centers for Disease Control (CDC) guidelines. Recommended HIV prophylaxis is based on results of the source blood testing. These recommendations are located in Appendix 2-G and 2-H.
Health department employees who sustain an exposure to a source person with HIV infection or a source person with clinical evidence of AIDS or symptoms of HIV infection should:
1. Be counseled regarding the risk of transmission and the potential efficacy of postexposure (PEP) medications. Postexposure evaluation and treatment with PEP meds may be obtained at either the employee‘s private physician or through the local emergency room, depending on resources available in that particular county. It is important to note that evaluation and 2011 Infection Prevention and Control Manual 18
treatment should not be delayed when indicated. When the employee is referred for postexposure evaluation and treatment, the employee should take the following items:
a. copy of ―Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis‖ MMWR, September 30, 2005/54(RR9);1-17.
*A copy of this document can be accessed at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm. Print a copy of this document to have on hand, which can be used by the physician when evaluating the need for PEP.
A copy of ―Notice to Readers‖: Updated Information Regarding Antiretroviral Agents used as HIV Postexposure Prophylaxis for Occupational HIV Exposures‖, MMWR. December 14, 2007/56(49);1291-1292. This document can be accessed at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5649a4.htm.
b. Copy of the OSDH Referral Policy: Postexposure Prophylaxis Appendix 2-I.
2. Be advised to seek medical evaluation for any acute febrile illness occurring within 12 weeks of exposure. Acute illness, particularly if characterized by fever, rash, myalgia, fatigue, malaise or lymphadenopathy, may be indicative of recent HIV infection.
3. Follow recommendations for preventing transmission of HIV until subsequent testing rules out HIV transmission to the employee. Appendix 2-J includes information for the employee who is exposed to HIV positive or high-risk clients.
The employee who is exposed to HIV should receive HIV-EIA testing at: baseline, 6 weeks, 12 weeks and 6 months
Extended HIV follow-up testing should be performed at 12 months for employees who become infected with HCV following exposure to a source that is coinfected with HIV and HCV.
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Infection Prevention Practices
s early as 1977, recommendations were published regarding isolation precautions used in healthcare settings to prevent spread of disease. Many changes have followed, and the current document is the ―Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007‖, created by the Healthcare Infection Control Practices Advisory Committee (HICPAC), a federal advisory committee that advises and develops guidelines Centers for Disease Control and Prevention (CDC) and the Secretary of the Department of Health and Human Services (HHS) regarding health care infection control and prevention. This revision addresses home care and ambulatory care settings for the first time as well.
As of 2008, the terminology has evolved from ―infection control‖ to ―infection prevention‖, as the priority has shifted to preventing the occurrence of healthcare-associated infections. Additionally, the Association for Professionals in Infection Control and Epidemiology (APIC) announced that infection control professionals would now be referred to as ―infection preventionists.‖The latest HICPAC guideline divides precautions into three categories. Standard Precautions are based on the principal that all blood, body fluids, secretions, excretions (except sweat), nonintact skin, and mucous membranes may contain contagious infectious agents. Standard precautions are used with all clients regardless of known disease status. Standard precautions include Respiratory Hygiene/Cough Etiquette, Safe Injection Practices and Infection Control Practices for Special Lumbar Puncture Procedures.
When Standard Precautions cannot completely interrupt the route of transmission of a known or suspected agent, the expanded Transmission-Based Precautions are used. There are three types of Transmission-Based Precautions: Airborne Precautions, Droplet Precautions, and Contact Precautions. Since many infections require laboratory confirmation, certain clinical syndromes and conditions are sufficient to warrant implementation of Transmission-Based Precautions while confirmatory tests are pending. This application of Transmission-Based Precautions is referred to as Syndromic/Empiric Precautions.
Standard Precautions
Use Standard Precautions for the care of all clients.
1. Hand hygiene- Includes both hand washing and use of alcohol-based products to be used without water. Perform appropriate hand hygiene immediately before and after client contact. Perform hand hygiene after touching blood, body fluids, secretions, excretions, mucus membranes, nonintact skin, wound dressings, or inanimate objects in the immediate vicinity of the patient. Perform hand hygiene
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immediately after gloves are removed. It may be necessary to perform hand hygiene between tasks and procedures on the same client to prevent cross-contamination of different body sites. Handwashing: Hands that are visibly soiled should be washed using either plain or antimicrobial soap and water. Wet hands with running water. Apply soap and thoroughly distribute over hands. Vigorously rub hands together for a minimum of 15-30 seconds, covering all surfaces of the hands and fingers. Rinse well and dry with an unused, dry towel or air dryer. Turn off faucet using dry towel. Avoid recontamination of hands on sink, sink components, or bathroom door handle after washing. Alcohol-based hand product (such as gel, rinse, or foam) method: May be used when hands are not visibly soiled. Apply a 60-95% ethanol or isopropanol alcohol based hand gel to the palm of one hand. Rub hands vigorously together, covering all parts of the hands until dry (usually about 30 seconds). Follow the manufacturer‘s recommendations regarding the volume of product to use. Because appropriate use of these products require less time, all OSDH sites should consider having this method available to improve hand-hygiene adherence. Alcohols are flammable; therefore, insure all alcohol has evaporated after using alcohol-based hand products, and store these products away from high temperatures or flames. Home visitors: It is recommended that home visitors carry liquid soap, paper towels and alcohol-based hand product for the purposes of hand hygiene, based on availability of running water. As stated above, hands that are visibly soiled should be cleaned using soap and water and dried well with paper towels.
Wash hands with soap and water or perform hand hygiene using alcohol-based hand product prior to weighing/measuring or other examination of infants and children in order to promote good hygiene and prevent the spread of bacteria.
After completing the home visit, the home visitor should use the alcohol-based hand product before entering his/her vehicle.
Washing hands with either plain or antiseptic-containing soap and water after use of an alcohol based hand product is not necessary and is not recommended, because it may contribute to dermatitis. Washing hands with soap and water after 5-10 applications of gel has been recommended by certain manufacturers for aesthetic purposes.
In order to maintain hand skin health, CDC recommends implementation of a routine schedule for applying lotions or creams. Avoid use of oil or petroleum-based hand lotions or creams which adversely affect the integrity of latex gloves and can contribute to latex sensitivity/allergy. Information should be solicited from the manufacturer regarding potential interactions with gloves. 2011 Infection Prevention and Control Manual 21
Antimicrobial-impregnated wipes or towelettes are not as effective as alcohol- based hand rubs or antimicrobial soap, and water for hand hygiene purposes, and should not be used as a substitute for hand hygiene in client care settings.
2. Fingernails and Artificial Nails - The subungual area (situated beneath the nail of a finger) of the hand harbors high concentrations of bacteria. Healthcare workers who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than those who have natural nails, both before and after handwashing. Therefore, artificial fingernails are discouraged in the clinical setting. All fingernails (artificial or natural) should be less than 1/4 inch long to reduce the colonization of the subungual area with bacteria. Freshly applied nail polish does not increase the number of bacteria recovered from periungual skin, but chipped nail polish may support the growth of larger numbers of organisms on fingernails.
3. Gloves- Wear gloves when touching blood, body fluids, secretions, excretions and contaminated items. Care must be taken to ensure that any hand jewelry does not interrupt the integrity of the gloves. Jewelry can cause tears in gloves and therefore it is recommended that jewelry be kept to a minimum when working in a client care environment. Gloves should be worn for specimen collection, cleaning and disinfecting client care equipment and environmental surfaces, handling contaminated personal protective equipment or clothing, or handling medical waste containers. Put on clean gloves just before touching mucous membranes and nonintact skin. Take care to avoid contaminating clean areas when wearing gloves.
Change gloves between tasks and procedures on the same client after contact with potentially infectious materials. Change gloves immediately if torn or the integrity of the glove is compromised. Remove gloves promptly after use, before touching noncontaminated items and environmental surfaces, and before going to another client. Perform appropriate hand hygiene immediately, because gloves can develop unnoticed holes or tears during use and hands may be contaminated. Wear the appropriate glove size to achieve a good fit. Latex sensitivity or latex allergy can develop following repeated exposure or use of latex items such as gloves, especially among healthcare workers. For this reason, the National Institute of Occupational Safety and Health (NIOSH) has these recommendations to minimize latex exposure (see reference section for document): Use nonlatex gloves when appropriate Use powder-free latex gloves with reduced protein content Wash hands thoroughly after removing gloves Use non-oil-based hand lotions or creams to avoid glove deterioration Thoroughly and frequently clean areas contaminated with latex-containing dust Recognize the symptoms of latex allergy: rash, hives, flushing, respiratory symptoms, asthma and shock. If you develop latex sensitivity or allergy, avoid contact with latex, notify your supervisor and consult a physician. 2011 Infection Prevention and Control Manual 22
4. Mask, Eye Protection, Face Shield- Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose and mouth during procedures and activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions. Select appropriate items as indicated by the task being performed. Examples of situations in which full-face protection would be indicated include culturing for pertussis, performing emergency OB-GYN exams, assisting in emergency childbirth or rendering first aid to a severely bleeding client. Full-face protection is indicated if it is reasonably anticipated that the client may cough in the face of the employee during collection of respiratory specimens. WARNING: Care must be taken when performing sharps procedures due to the reduced field of view when wearing protective masks. Visibly or suspected contaminated face protection must be changed whenever wet and between each client.
It is recommended that home visitors carry in their bag that is taken into the home a minimum of two disposable surgical masks. If the client is coughing, the home visitor should don a mask to protect himself or herself against droplet transmission. Under these circumstances, the visit may be completed as scheduled.
5. Lab Coat/Jacket- Wear a cloth or fluid resistant lab coat/jacket to protect skin and to prevent soiling of clothing during procedures and activities that are likely to generate splashes or sprays of blood, body fluids, secretions, or excretions. General work clothes (i.e., uniforms, pants, shirts or blouses) are not intended to function as personal protective equipment. Remove a soiled lab coat/jacket as promptly as possible, minimizing contamination. If contaminated with blood or body fluids, the lab coat/jacket must be promptly replaced with a clean lab coat/jacket. Refer to Guidelines for the Work Setting, Management of Contaminated Non-disposable Lab Coats and Other Laundry in this section.
6. Footwear- Sandals, open-toed shoes, shoes with holes that expose the feet (including Crocs™), or shoes with open backs are not to be worn in any laboratory or client care areas in accordance with OSHA Bloodborne pathogen standard 1910.1030(d)(3)(i) and OSHA Personnel Protective Equipment Regulation 1910.132 OSHA interpretation of the use of Crocs™ brand shoes states that when a risk of foot injuries due to falling or piercing objects (such as needles) would be an environment which could cause foot injury and protective foot ware would be required.
7. Equipment/Environmental Control- Handle equipment that is soiled with blood, body fluids, secretions or excretions in a manner that prevents skin and mucous membrane exposures, contamination of clothing and transfer of microorganisms to one‘s self, other clients and environments. Contaminated needles and other contaminated sharps shall not be bent, recapped or removed. The current directive from OSHA, CPL2-2.69 at XIII.D.5 states, ―removing the needle from a used blood-drawing/phlebotomy device is rarely, if ever, required by a medical procedure. Because such devices involve the use of a double-ended needle, such removal clearly exposes employees to additional risk, as does the increased manipulation of a contaminated device.‖ In order to prevent potential worker exposure to the contaminated hollow bore needle at both the front and back ends, it is required that vacutainer holders with retractable technology be utilized for 2011 Infection Prevention and Control Manual 23
phlebotomy procedures. All vacutainer tube holders are to be considered single use and discarded after each use.
Ensure that reusable equipment is not reused for the care of another client until it has been cleaned and reprocessed appropriately. Use PPE appropriately when cleaning contaminated equipment. Ensure that single-use items are discarded properly. Follow Guidelines listed in Section 4 for decontamination and cleaning of equipment and environment.
8. Occupational Health and Bloodborne Pathogens- All procedures involving blood or other potentially infectious materials shall be performed in such a manner as to minimize splashing, spraying, spattering and generation of droplets of these substances. Never recap used needles. Do not remove used needles from disposable syringes by hand, and do not bend, break or otherwise manipulate used needles. Immediately place used disposable syringes and needles in an appropriate puncture-resistant container that is labeled or color-coded [in accordance with CFR 1910.1030(d)(2)(vii)(B)], which should be located as close as practical to the area in which the items were used. Specimens of blood or other potentially infectious materials shall be placed in a container that prevents leakage during collection, handling, processing, storage, transport or shipping.
9. Eyewash Station Requirements- Eye wash stations must be provided in work areas where the eyes and body may be exposed to any injurious material or material containing bloodborne pathogens to provide immediate use in accordance with OSHA 1910.151 (c). An eyewash station must provide a controlled flow of water to both eyes simultaneously at a velocity low enough not to injure the user. It must deliver at least 3 gallons per minute for 15 minutes at a minimum of 30 psi (pounds per square inch) of flow pressure. It must be large enough to provide room for the eyelids to be held open with the hands while the eyes are in the stream of water. Emergency eyewash stations must be located where employees can easily access them, in a well-lighted area identified with a sign. It should be located in an area that requires no more than 10 seconds for employees to reach or approximately 100 feet. Activate weekly to flush the line, verify proper operation, and record on log.
10. Respiratory hygiene/cough etiquette- is included in Standard Precautions to address spread of undiagnosed transmissible respiratory infections. The components of respiratory hygiene/cough etiquette include (1) education of employees, clients and visitors regarding appropriate cough etiquette; (2) posted signs in appropriate languages describing the concepts; (3) source control measures such as appropriate use of a tissue, prompt disposal of used tissues, use of surgical or procedural masks on coughing clients; (4) hand hygiene after contact with respiratory secretions or items/surfaces contaminated with respiratory secretions; and (5) spacial separation, ideally >3 feet of symptomatic persons from others while in common areas such as waiting rooms.
11. Safe injection practices- include the basic aseptic techniques for the preparation and administration of injectable medications. These include use of sterile, single-use, disposable needles and syringes for each injection given and preventing contamination of medication and equipment. 2011 Infection Prevention and Control Manual 24
Transmission Based Precautions
See Table in Appendix 3-A for Type and Duration of Precautions to Use for Selected Infections and Conditions.
1. Airborne Precautions- In addition to Standard Precautions, use Airborne Precautions for clients known or suspected to be infected with microorganisms transmitted by airborne droplet nuclei, which remain suspended in the air over long distances. Examples include measles, chickenpox, tuberculosis, and possibly influenza and SARS. Such clients are priority clients and should be seen immediately. If the airborne infection isolation room is being used and other clients present to the clinic with signs and symptoms of an airborne transmissible disease, they should be given priority and the TB Nurse/nurse should be notified and see them as soon as possible. Alternately, these clients may be, sent outside of the building to wait, and should be monitored as potential flight or communicable disease risks if they do not adhere to instructions. Airborne droplet nuclei remain suspended in air and are dispersed widely by air currents indoors, but are diluted and destroyed by natural sunlight, making them much less likely to be a communicable disease risk outdoors. In the clinic setting, place the client in the airborne infection (negative airflow) isolation room. Keep the room door closed. Alternately instruct the client to remain outside in a designated location. Provide the client with a disposable surgical mask and instruct him/her regarding respiratory hygiene and cough etiquette. Provide tissues, waste container, and access to hand hygiene products. Wear respiratory protection (N95 respirator) when entering the room or home. See Section 6 for additional guidelines for working with clients with tuberculosis. Susceptible persons should not enter the room or the home of clients known or suspected to have measles or varicella if other immune caregivers are available. Due to difficulties in confirming definite immunity, the HICPAC guideline does not have a recommendation for health care workers who are immune or have been adequately vaccinated against measles or varicella, and are caring for a client who is infected or suspected with measles or varicella. The type of respiratory protection for immune healthcare workers is also an unresolved issue in the guideline. Therefore healthcare workers presumed to be immune should wear N95 respirators when caring for clients with suspected or confirmed measles or varicella.
2. Droplet Precautions- In addition to Standard Precautions, use Droplet Precautions for a client known or suspected to be infected with microorganisms transmitted by large particle droplets, which are spread through close respiratory or mucous membrane contact with respiratory secretions. The client can generate droplets during coughing, sneezing, talking, or singing. Examples of such illnesses include Haemophilus influenza type b, Neisseria meningitis, Diphtheria, Pertussis, Pneumonic plague, Streptococcal (group A) pharyngitis, pneumonia, Scarlet fever, Influenza, Mumps and Rubella. 2011 Infection Prevention and Control Manual 25
Instruct clients suspected to have a droplet spread illness on the use of Respiratory Hygiene/Cough Etiquette. Keep client separated from other clients. Place into an exam room as soon as possible. If delayed, place a surgical or procedure mask on the client and place him/her 3-6 feet from others. Wear a mask when entering the client‘s room. In the home setting, in situations where the visit cannot be rescheduled, use a mask when working within 3-6 ft. of the client.
3. Contact Precautions- In addition to Standard Precautions, use Contact Precautions for clients known or suspected to be infected or colonized with microorganisms that can be transmitted by direct contact with the client or indirect contact with contaminated environmental surfaces or items. Blood and body fluids are important sources of disease-causing organisms potentially spread through contact transmission. Examples include major draining wounds, Clostridium difficile, acute viral conjunctivitis, herpes simplex, lice, respiratory syncytial virus (RSV), and shingles (varicella zoster). Examples of chances for indirect contact transmission include hands that are not cleaned after becoming contaminated, patient-care devices that are not cleaned between patients, shared items such as toys among pediatric patients, and instruments that are not correctly cleaned between patients before disinfection or sterilization. Wear gloves for all interactions with the client, items belonging to the client or when touching surfaces potentially contaminated by the client. During the course of providing care for a client, change gloves after having contact with infective material. Remove gloves before leaving the room and perform hand hygiene immediately. Wear a cloth or fluid resistant lab coat/jacket if you anticipate that your clothing will have substantial contact with the client, or if the client is incontinent or has diarrhea, an ileostomy, a colostomy or wound drainage not contained by a dressing. Remove the cloth or fluid resistant lab coat/jacket before leaving the client‘s environment. Adequately clean and disinfect equipment according to guidelines in Section 4 prior to use for another client.
Infection Prevention and Control for Potential Bioterrorism Agents
As a consequence of the terrorist attacks on September 11, 2001 and the anthrax mail attacks that closely followed during October – November, 2001, public health workers assumed a leadership role in terrorism preparedness and response. It is recommended that all county health department administrators, nurses, and public health specialists familiarize themselves with the following list of potential bioterrorism agents and their respective transmission precautions. These agents cover a broad spectrum of biological pathogens, including bacteria, viruses and toxins. In some instances, it will not be possible for first responders to recognize which disease agent they are initially dealing with, or if it is a biological attack rather than a naturally occurring disease outbreak. When the agent is unknown, droplet precautions-- at a 2011 Infection Prevention and Control Manual 26
minimum--should be exercised when interacting with affected clients until the infecting agent can be confirmed by laboratory testing at the OSDH Public Health Laboratory or the CDC.
The CDC has categorized potential biological agents of terrorism into the following three categories:
Category A – potential agents include those that cause: anthrax; botulism; plague; smallpox; tularemia; and viral hemorrhagic fevers. These are high priority agents because the organisms pose a risk to national security due to the following characteristics: Can be easily disseminated or transmitted from person to person Result in high mortality rates and have the potential for major public health impact Might cause public panic and social disruption Require special action for public health preparedness
Category B – potential agents or resulting conditions include: Brucellosis; food safety threats (Salmonella, Escherichia coli, Shigella); Glanders; Q-Fever; Ricin toxin; Staphylococcal enterotoxin B; Typhus fever; Viral encephalitis (alphaviruses); and, water safety threats (Vibrio cholerae and Cryptosporidium parvum). These are considered second highest priority agents due to the following characteristics: Are moderately easy to disseminate Result in moderate morbidity rates and low mortality rates Require specific enhancements of CDC and state health departments‘ diagnostic capacity and enhanced disease surveillance.
Category C – potential agents include: emerging infectious disease agents such as Nipah virus and Hantavirus. These are considered the third highest priority due to the following characteristics: Availability Ease of production and dissemination Potential for high morbidity and mortality rates and major health impact
The public health work force should employ transmission-based precautions when handling clients where a bioterrorism event is suspected or confirmed. A higher level of precautions may be required to safely handle environmental specimens contaminated with a biological agent. It should also be noted that human cases of anthrax, botulism and tularemia occur sporadically in our state from natural exposures. For guidance in these situations, contact the Acute Disease Service Epidemiologist-on-Call at 405-271-4060. Calls to this number after business hours, weekends and holidays will be returned within 15 minutes. 2011 Infection Prevention and Control Manual 27
Isolation Precautions for Bioterrorist Agents
Standard
Contact
Droplet Precautions
Airborne
CATEGORY A - Potential Agents
Anthrax (B. anthracis), Botulism (C. botulinum toxin), Tularemia (F. tularemia)
X
Pneumonic plague (Yersinia pestis)
X
X
Smallpox (Variola major virus)
X
X Viral Hemorrhagic Fevers (VHFs) Marburg, Ebola, or Arenaviruses
X
X
X
X
CATEGORY B & C - Potential Agents
Brucella spp. (Brucellosis), Salmonella, Escherichia coli, Shigella, Burkholderia mallei (Glanders), Coxiella burnetti (Q-Fever), Staphylococcal enterotoxin B, Rickettsia prowazekii (Typhus fever), alphaviruses (Venezuelan Equine Encephalitis, Eastern Equine Encephalitis) , Vibrio cholerae (Cholera), Cryptosporidium parvum (Cryptosporidiosis), Ricin toxin, Nipah virus, and Hantavirus
X
See Table in Appendix 3-A for Type and Duration of Precautions to Use for Selected Infections and Conditions.
Guidelines for the Work Setting
1. When there is the risk of occupational exposure, the employer shall provide, at no cost to the employee, appropriate protective equipment such as, but not limited to, gloves, gowns, laboratory coats, face shields or masks and eye protection, and mouthpieces, resuscitation bags, pocket masks or other ventilation devices. Personal protective equipment will be considered ―appropriate‖ only if it does not permit blood or other potentially infectious materials to pass through to or reach the employee‘s works clothes, street clothes, undergarments, skin, eyes, mouth or other mucous membranes under normal conditions of use for the duration of time, which the protective equipment will be used [CFR 1910.1030 (d)(3)(i)]. 2011 Infection Prevention and Control Manual 28
2. The employer shall ensure that the employee uses appropriate personal protective equipment unless the employer shows that the employee temporarily and briefly declined to use personal protective equipment when, under rare and extraordinary circumstances, it was the employee‘s professional judgment that in the specific instance its use would have prevented the delivery of health care or public safety services or would have posed an increased hazard to the safety of the worker or co-worker. When the employee makes this judgment, the circumstances shall be investigated and documented in order to determine whether changes can be instituted to prevent such occurrences in the future [CFR 1910.1030 (d) (3) (ii)].
3. Use of Personal Protective Equipment/Clothing- Personal protective equipment and clothing is designed to place a fluid-resistant barrier between the health care provider and the blood or other body fluids of the client. All such equipment and clothing must be provided and maintained by the county health department administration. Employees are not to take contaminated personal equipment or clothing home under any circumstances or for any purpose, nor are they to wear it outside of the clinic area.
4. Management of Client Specimens-
a. Handling: To avoid contamination of environmental surfaces and exposure to the employee, client specimens must be handled with care to prevent breakage, spillage or contamination of outer container. Gloves must be worn. Immediately clean any spills that occur, following guidelines found in Section 4 of this document.
b. Transport and Mailing: Blood specimens must be collected in the appropriate water tight, sealed tube and placed in a sealed water tight plastic bag. The bag must contain sufficient absorbent material. The bag must be placed in an outer shipping container that is made from fiberboard or equivalent material. The container must be labeled as biohazardous and should state that the package complies with 42 CFR 72.3 (d) of the Postal Regulations. See the Public Health Laboratory Resource Manual for additional instructions.
5. Management of Contaminated Non-disposable Lab Coats and Other Laundry- Gloves and other appropriate protective apparel should be worn by persons handling contaminated clothing. Once contaminated, non-disposable lab coats or any other clinic laundry must be placed in a fluid-resistant container that is red in color and/or marked with the universal biohazard symbol. Washing in hot water in a standard automatic washing machine is sufficient for decontamination. Adding bleach to the wash cycle is not required. Since employees cannot take these items home, the OSDH or County Health Department must ensure the laundry is done on site, taken to a local self-service laundry, or taken to a commercial laundry. Commercial dry-cleaning of fabrics soiled with blood also renders these items free of the risk of pathogen transmission. If a commercial laundry is used, contaminated laundry must be transported in colored or labeled containers or bags as indicated above, and the laundry must be informed if they are receiving contaminated items. It is recommended that only those commercial laundries, which are known to be implementing the OSHA Bloodborne Pathogen Standard, be used. Lab coats that are soiled with dirt and not visibly contaminated by body fluids may be taken home by the employee for laundering. 2011 Infection Prevention and Control Manual 29
If clothing becomes contaminated during a home visit, and spare clothing is available, change into clean clothing and carefully place contaminated clothing into a plastic bag. If spare clothing is not available, place a disposable impervious gown over clothing and return home to change into clean clothes, showering if gross contamination occurred. Notify your supervisor as soon as feasible.
6. Work Areas- Eating, drinking, smoking and personal grooming are prohibited in work areas where there is a reasonable likelihood of occupational exposure. Also, food and drink may not be stored in a refrigerator, freezer, or other container or shelf where any medication or client specimens such as blood or other potentially infectious materials, are stored. A sign should be placed on the door of these areas, which indicates that no food or drink is allowed. CLIA regulations may place additional restrictions on management of laboratory specimens. Consult with the Public Health Laboratory, (405) 271-5070 for clarification if needed. 2011 Infection Prevention and Control Manual 30
2011 Infection Prevention and Control Manual 31
Guidelines for Cleaning, Disinfecting and Sterilizing
isted below are recommended procedures for management of equipment in county health department clinics, and equipment used in the home setting. In following the recommendations, it should be noted that household bleach solutions are less effective as disinfectants in the presence of high concentrations of protein. Hence it is important to first remove as much body fluid as possible before decontamination. Depending on the degree of contamination, the difficulty penetrating the contaminated area, and the ability of the surface to withstand exposure to bleach solution, a 1:10 to 1:100 dilution of bleach may be used. Contaminated containers or equipment that routinely store client specimens (i.e., centrifuges, freezers or refrigerators holding specimens, etc.) must be labeled as biohazardous using an adhesive biohazard label or a securely attached biohazard tag. Check manufacturer‘s directions before cleaning equipment. Contaminated equipment, supplies or environmental items that cannot be adequately disinfected should be removed from use, labeled as biohazardous using an adhesive biohazard label or securely attached biohazard tag and processed per manufacturer recommendations.
Product Sterility and Shelf-life
Sterility of a product, either purchased or packaged by OSDH, is event related. Nurses have a responsibility to use guidelines and good nursing judgment when evaluating products and packaging. Products, such as VanishPoint syringes, may contain a shelf-life date. This is usually the date the manufacture guarantees sterility of the product. The Association for the Advancement of Medical Instruments standards summarize product sterility as event related under intact packaging guidelines. Events that may compromise the sterility of a package include:
1. Multiple handling that leads to seal breakage or loss of package integrity,
2. Moisture penetration,
3. Airborne contaminants.
Section
4
L 2011 Infection Prevention and Control Manual 32
Prior to use, examine the equipment package for evidence of loss of integrity. Discard any single-use devices that have been exposed to floodwaters or have evidence of exposure of uncertain history, even if the packaging and seals appear to be intact.
Disinfectant Solutions
1. 1:10 dilution household bleach- 1 part household bleach to 9 parts water. May be made in quantity for one-week use. Label with expiration date.
2. 1:100 dilution household bleach- 1 part household bleach to 99 parts water. Must be made daily and discarded at the end of the day to assure effectiveness. 1 oz. household bleach in 3 quarts water makes an actual dilution of 1:97, which is acceptable.
3. Other solutions- Any commercial disinfectant labeled as Tuberculocidal when diluted according to manufacturer‘s specifications.
4. 1:10 Disinfectant Wipes- Disposable disinfectant wipes meeting a 1:10 dilution of household bleach are considered an acceptable disinfectant product. Use according to package directions.
Note that there is an association between the excessive use of a phenolic disinfectant and hyperbilirubinemia in newborns. A phenolic product must not be used on surfaces that may come in contact with infants.
General Area Maintenance
1. Office Area- The area should be kept neat and dust free when possible. Regular vacuuming and/or mopping is recommended. Routine cleaning and disinfection of office equipment, such as the telephone handset and countertops is recommended to help prevent the spread of viruses in office settings.
2. Client Waiting Areas and Restrooms- Thorough environmental cleaning of client waiting areas and restrooms should be done routinely with a disinfectant solution. Waiting area floors and items found in the waiting area such as chairs, and tables should be cleaned and disinfected daily. Clients should be encouraged to bring their own toys from home when necessary. Chairs in client waiting areas should be spaced in such a manner as to avoid body contact between seated individuals. Only the client should handle the client‘s clothing and outerwear. Devices such as coat trees should not be available in client waiting areas. Optimally, individual outerwear should be kept with the client or placed on wall hooks 12 inches apart. Employee‘s outerwear should be managed in the same manner as that of clients. Clients recognized to have a disease spread by contact transmission, such as skin infections or scabies, should be directed to an area away from other clients. For guidelines regarding clients who are coughing, see Section 5 “Guidelines For the Prevention of Respiratory Transmitted Diseases”.
Restroom items such as toilet stalls, sinks and floors should be cleaned and disinfected daily and when visibly soiled. 2011 Infection Prevention and Control Manual 33
3. Work Areas and Equipment Surfaces- Clinic room tables, countertops, floors and sinks should be cleaned and disinfected daily and when visibly soiled. Equipment used for home visits, such as portable scales, should be disinfected between client visits. After each client clean visible blood and body fluid spills from all exam tables and infant scale pans with detergent and water, then decontaminate with 1:10 dilution of household bleach solution or an approved disinfectant. Rinse with clean water to prevent damage when household bleach solution is used. Exam table paper must be changed between each client.
Wipe down exam and scale table surfaces, equipment and work surfaces at the end of each day with 1:100 dilution of household bleach solutions or an approved disinfectant after cleaning any visible soiling. Rinse with water to prevent damage when household bleach is used. Wall hooks should be placed in the examination room and clients should be instructed to hang their clothing rather than placing on floor or chair.
Clean visible blood and body fluid spills from all laboratory equipment, surfaces, cabinets and work surfaces with detergent and water. Then decontaminate with 1:10 dilution of household bleach solution or an approved disinfectant solution. Rinse with clean water to prevent damage when bleach is used.
Wipe down laboratory equipment and work surfaces at the end of each day with 1:100 dilution of household bleach solutions or an approved disinfectant after cleaning any visible soiling. Rinse with water to prevent damage when household bleach is used.
4. Toys-- Toys and other objects that are used by service providers in the assessment and evaluation of clients should be washed with soap and water and rinsed in a dilute bleach solution followed by a fresh water rinse between clients and at least daily. Toys mouthed by children should be washed and rinsed as specified above before any other child uses the toy. Any toy that cannot be easily cleaned (such as stuffed animals which cannot be machine washed) must not be shared among children in county health departments.
5. Decontamination of Spills- When cleaning spills the appropriate personal protective equipment (PPE) must be worn to prevent contamination. Wear gloves at a minimum and wear a mask if fluids may be splashed or aerosolized during cleanup.
a. Moist spills: Absorb the spill with disposable towels. Using a detergent solution, clean the spill site of all visible blood or body fluid. Wipe down with 1:10 dilution of household bleach solution or an approved disinfectant solution. Dispose of all materials used to decontaminate the spill as directed in Section 5.
b. Dry spills: If a surface or medical device is contaminated with dried blood or body fluid, remove all of it before disinfection. Following removal, wipe down with 1:10 dilution of household bleach solution or an approved disinfectant solution and rinse. 2011 Infection Prevention and Control Manual 34
Medical Equipment
1. Classification of Medical Equipment- For the purposes of this section, medical equipment is defined as critical, semicritical or noncritical.
a. Critical: Enters normally sterile tissue or the vascular system. All critical medical equipment should be purchased as sterile or be sterilized by steam under pressure. This category includes surgical instruments, urinary catheters, implants and needles.
b. Semicritical: Contacts mucous membranes or nonintact skin. These items must be free of all microorganisms, with the exception of high numbers of bacterial spores. Semicritical items generally require high-level disinfection. Most dental instruments, all instruments used for vaginal exams or procedures and respiratory equipment require high-level disinfection/sterilization. Thermometers, however, require only intermediate-level disinfection.
c. Noncritical: Comes into contact with intact skin. All noncritical medical equipment must be cleaned when visibly soiled. If contaminated with blood or body fluids, contaminated portions of the equipment must be thoroughly cleansed with a disinfectant solution. Examples of noncritical medical equipment include stethoscopes, otoscopes and blood pressure cuffs. These items require low-level disinfection.
2. Methods of Disinfection and Sterilization-
Used metal speculums are to be placed in soapy water immediately after use. The container must have a lid that seals. A sealable bucket or plastic tote may be used if kept in the clinic room. Open buckets are NOT to be utilized in the clinic room. Sterilization: A process by which there is complete elimination or destruction of all forms of microbial life. This can be accomplished by autoclaving. Prior to sterilization, the equipment must be thoroughly cleansed to remove all visible body fluids. After cleansing, place equipment in open metal autoclave pans. Autoclavable plastic pans are not effective. Equipment should be autoclaved for the time necessary to achieve and maintain a temperature of 121 C and a pressure of 15 psi for 30 minutes or longer. Typically, this will require at least one hour of autoclave time, depending on the type and size of the load. High-level disinfection: A process, which can be expected to destroy all microorganisms, with the exception of high numbers of bacterial spores. This can be accomplished by autoclaving.
Glutaraldehyde should not be used in the county health department. The county health department has the following choices: 2011 Infection Prevention and Control Manual 35
a. Items requiring sterilization may be autoclaved. County health department autoclaves are to be monitored using the guidelines listed in Laboratory Equipment #6: Autoclaves.
b. County health departments may choose to seek an agreement with a local hospital for autoclave services.
c. County health departments may choose to use disposable speculums in lieu of autoclaving. Intermediate-level disinfection: A process that inactivates Mycobacterium tuberculosis, vegetative bacteria, most viruses and most fungi, but does not necessarily kill bacterial spores. Smooth, hard surfaces can be disinfected with 1:10 household bleach solution or a commercial disinfectant with label claim for tuberculocidal activity. It is highly recommended that thermometer sheaths be used if disposable thermometers are not available. OSHA recommends discontinuing the use of glass mercury thermometers. http://www.osha.gov/SLTC/etools/hospital/hazards/mercury/mercury.html. Intermediate-level disinfection of glass thermometers can be achieved by soaking in 70%-90% isopropyl alcohol for at least 20 minutes. Do not mix thermometers used for oral and rectal use. Contaminated blood pressure cuffs, stethoscopes, and tourniquets may be disinfected with a 70% alcohol solution. Home visitors: All equipment that is taken into the home and used on clients must be properly disinfected after each use and before it is returned to the home visitor‘s vehicle. Equipment that has not been cleaned and disinfected after use may not be used on other clients. Low-level disinfection: A process which kills most bacteria, some viruses, and some fungi, but it cannot be relied on to kill resistant microorganisms such as tubercle bacilli or bacterial spores. Low-level disinfection can be accomplished by using a hospital disinfectant without label claim for tuberculocidal activity or a 1:100 dilution of household bleach.
Laboratory Equipment
Always follow manufacturer‘s instructions for routine cleaning and maintenance of equipment.
1. Blood Collection Equipment and Supplies-
Vacutainer System: Retractable vacutainer systems should be used for all venipunctures if possible. The entire retractable unit must be disposed of in an appropriate sharps container (see Section 5 for more on sharps disposal). Nonretractable vacutainer systems are never recommended. Retractable Butterfly and syringe units may be used on infants with strict attention to occupational health and safety.
Fingerstick Lancets: The OSDH requires the use of retractable lancet devices and single-use disposable lancets. 2011 Infection Prevention and Control Manual 36
2. Centrifuges-
Whole Blood: These centrifuges for spinning samples to obtain serum should be operated in an area away from clients and in a closed cabinet or enclosed area to prevent the general air distribution of aerosols should a tube of blood break. Every precaution should be taken to prevent breakage such as using a balance tube with an equal volume of water as the blood sample, across from the specimen.
Should a sample break in the centrifuge, heavy-duty polyurethane gloves must be worn and forceps must be used to remove particles of broken glass. Excess blood in the centrifuge should be removed prior to decontamination. The tube shields or trunnions should be removed and immersed in 1:10 dilution of household bleach for 10 minutes then rinsed with fresh water, dried, and the concave (aqua or black colored) cushion repositioned in the bottom of the shield or trunnion before returning to the centrifuge rotor head. The rotor head and bowl, if the centrifuge has one, should be wiped with 1:10 dilution of household bleach, and then with fresh water to remove the corrosive household bleach solution. Disinfectant wipes as described in Section 4, ―Guidelines for Cleaning, Disinfecting & Sterilizing‖ may be used to wipe the rotor head and bowl, followed by a clear water rinse.
3. Microscopes-
After contamination, the stage and controls may be wiped off with a suitable cleaning agent followed by a disinfectant or 1:100 dilution of household bleach and followed immediately with a fresh water rinse. The objective lens, eyepieces, lamp and condenser should be cleaned with lens cleanser and lens paper.
4. HemoCue Machine (Hemoglobin)-
Microcuvettes should be immediately disposed of in an appropriate sharps container following use. The HemoCue machine should be disinfected daily using 1:100 bleach solution. The slide out mechanism arm should be removed and disinfected weekly. At any time, visible blood should be immediately removed and followed by disinfection with a 1:10 bleach solution or an approved disinfectant, then wiped with fresh water.
5. Autoclaves-
Autoclaves must be monitored according to manufacturer‘s recommendations on a routine basis to ensure proper sterilization is being accomplished. While the use of heat sensitive dye markers is useful for monitoring individual loads, more sensitive biological monitoring must be performed and documented on a weekly basis. Biological monitoring can be accomplished using spore strips or vials that are placed as close to the center of the load as possible and subsequently incubated.
Correct sterilization of any item depends on several factors, mainly thorough cleaning of the item, proper preparation, packaging and positioning of the items in the load, and verification of the correct exposure time and temperature. Follow the manufacturer‘s recommendations to insure that steam reaches all surfaces of the items, and allows for effective steam removal to achieve proper drying. 2011 Infection Prevention and Control Manual 37
a. Arrange items so that they are not touching other items or the sides or door of the autoclave chamber. Do not overload or crowd items into the chamber.
b. If wrapped and non-wrapped items are being processed in the same load, use time/temperature guidelines for the wrapped items.
c. With each load: use heat sensitive chemical test strips that change color when a temperature of 121° C has been maintained for at least 12 minutes. Any items in a load where the test strip did not change color are NOT considered to be sterile.
d. Weekly or with each load if run less than weekly: perform biological testing using spore (Bacillus stearothermophilus) strips or vials per manufacturer‘s instructions. Interpret results per manufacturer‘s instructions. Results should be interpreted according to the instructions of the manufacturer. See Appendix 4-A for options of obtaining supplies and services for biologic monitoring.
e. Documentation: maintain a log book with the following criteria: (See Appendix 4-A for sample Autoclave Monitoring Log):
i. Each load: Record the date, type of items in the load, temperature, pressure, length of cycle, results of chemical indicators, results of biological indicators (when used), and signature of operator. To maintain a temperature of 121 C for 30 minutes or longer will typically require at least one hour of autoclave time, depending on the type and size of the load.
ii. At least once each week: Record the date quality control was performed, the basic content of the load (dental instruments, medical waste, etc.) date, temperature, pressure, length of cycle, signature of operator and the results of the biological monitoring of that load.
f. In the event an autoclave is determined to not be functioning appropriately to achieve sterilization (temperature of 121 and pressure of 15 psi not maintained for 30 minutes, or failure to pass heat sensitive or biologic monitoring), the materials must not be used and considered unsterile. The autoclave should be removed to a storage area until repaired or labeled as malfunctioning, and the administrative director notified.
g. If the facility rarely or irregularly uses the autoclave, consider establishing an agreement with a nearby hospital (or other licensed healthcare facility) to perform autoclave sterilization. Transport cleaned and wrapped (if appropriate) items to the facility in a closed container and transport autoclaved items back to the health department in a clean closed container. 2011 Infection Prevention and Control Manual 38
Records must be kept locally which verify the operating efficiency of autoclaves as monitored by heat sensitive and biologic monitoring methods.
Dental Instruments and Equipment
1. Dental Instruments- Any item that is used in the mouth and will be reused on another patient is to be cleaned, packaged, and heat-sterilized between uses using FDA-cleared sterilizers. Currently, OSDH dental clinics utilize steam-under-pressure sterilizers (autoclaves). If the item is heat-sensitive, it needs to be cleaned then sterilized by immersion in a liquid chemical cleared by FDA as a sterilant. Instruments need to be thoroughly cleaned prior to sterilization using cleaning equipment such as an ultrasonic. Before sterilization, inspect instruments for cleanliness, then wrap or place them in containers designed to maintain sterility during storage. Patient-care items are categorized as critical, semicritical, or noncritical, depending on the potential risk for infection associated with their intended use. Critical items such as surgical and other instruments that normally penetrate soft tissue or bone (i.e. forceps, scalpels, bone chisels, scalers and surgical burs) must be sterilized after each use or discarded. Semi-critical items touch mucous membranes or nonintact skin and have a lower risk of transmission; because the majority of semicritical items in dentistry are heat-tolerant, they also should be sterilized by using heat. If a semicritical item is heat-sensitive, it should, at a minimum, be processed with high-level disinfection. Noncritical patient-care items pose the least risk of transmission of infection, contacting only intact skin, which serves as an effective barrier to microorganisms. These should be cleaned with an EPA-registered hospital disinfectant with a tuberculocidal claim. Use of disposable barrier protection of these items might be a preferred alternative.
2. Monitoring- Monitoring of sterilization procedures should include a combination of process parameters, including mechanical, chemical, and biological. Monitor each load with mechanical (time, temperature, pressure) and chemical indicators. Biological indicators (i.e. spore tests) are the most accepted method for monitoring the sterilization process. Biological monitoring should be conducted weekly (or each clinic day if operations are conducted less than weekly). Mail-in monitoring services can be provided from private companies or dental schools. It is recommended that a monitoring log book be maintained.
In case of a positive spore test, remove the sterilizer from service and retest. If the repeat spore test is negative, put back into service. If the repeat spore test is positive, do not use the sterilizer until it has been inspected or repaired. Recall (to the extent possible) and reprocess all items processed since the last negative spore test. Before placing the sterilizer back into service, rechallenge the sterilizer with biological indicator tests in three consecutive empty chamber cycles after the cause of the failure has been determined and corrected. If instruments are to be stored after sterilization, they should be wrapped or bagged before sterilizing, using a suitable wrap material such as muslin, clear pouches, or paper as recommended by the manufacturer of the sterilizer. Following sterilization, the instruments should be stored in the sealed packages in a storage area with limited access, such as a closed cabinet. Event-related storage practices maintain that the contents of the package 2011 Infection Prevention and Control Manual 39
may be considered sterile unless the package is torn, wet, improperly stored or improperly or excessively handled, or is found to be contaminated. In these events, the contents of the package must be repackaged and resterilized.
3. Dental Handpieces- Dental handpieces, prophy angles and contra angles must be heat sterilized between clients with acceptable methods, which assure internal as well as external sterility. Disposable prophy angles are available and are to be discarded after one time use. The manufacturer‘s instructions must be followed for proper sterilization of handpieces, prophy angles and contra angles and for the use and maintenance of water lines and check valves. All dental units must have a check valve to prevent infective materials from being aspirated back into the water line. The first step before sterilization is to flush the handpiece with water by running it for 20 to 30 seconds, discharging the water into a sink or container. An ultrasonic cleaner should be used to remove any adherent material, but only if recommended by the handpiece manufacturer. Otherwise, the handpiece should be scrubbed thoroughly with a detergent and hot water. Many manufacturers recommend spraying a cleaner/lubricant into the assembled handpiece before and after sterilization. If in doubt as to whether a handpiece can be sterilized, contact the manufacturer.
4. Air/Water Syringes and Ultrasonic Scalers- Units should be flushed as described for handpieces. These attachments should be sterilized in the same manner as the handpieces, or in accordance with manufacturers‘ instructions. It is recommended that removable or disposable tips be used for these instruments and discarded after each client use.
5. Operatory Surfaces- Countertops and dental equipment surfaces such as light handles, x-ray unit heads, amalgamators, cabinet and drawer pulls, tray tables and chair switches are likely to become contaminated with potentially infectious materials during treatment procedures. These surfaces can be either covered or disinfected. Barrier protection can be provided by covering surfaces with plastic wrap, aluminum foil or impervious-backed absorbent paper. These protective coverings must be changed between clients and when contaminated.
If barriers are not used, surfaces should be cleaned and disinfected between patients by using a low-level EPA-registered hospital disinfectant with an HIV, HBV claim or a high-level tuberculocidal claim. Housekeeping surfaces, including floors, sinks, and related objects are not likely to be associated with the transmission of infection. However, the removal of visible soil and cleaning should be undertaken on a routine basis. Cleaners with germicidal activity may be used. Dental health care providers should wear gloves and other PPE to prevent occupational exposure to infectious agents and hazardous chemicals.
6. Impressions, Prostheses, Casts, Wax Rims, Jaw Relation Records- Items such as impressions, jaw relation records, casts, prosthetic restorations and devices, which have been in the client‘s mouth, should be properly disinfected prior to shipment to a dental laboratory. These items should be sprayed or immersed with an EPA-registered hospital intermediate-level disinfectant with a tuberculocidal claim when a laboratory case is sent off-site. Impressions must be rinsed to remove saliva, blood 2011 Infection Prevention and Control Manual 40
and debris and then disinfected. Impressions can be disinfected by immersion in a compatible disinfecting product. Since the compatibility of an impression material with a disinfectant varies, the impression material manufacturer‘s recommendations for proper disinfection should be followed. Disinfected impressions, which are sent to the dental laboratory, should be labeled as such in order to prevent duplication of the disinfection protocol.
7. Special Considerations- In dental radiology, the potential to cross-contaminate equipment and surfaces with blood or saliva is high if aseptic technique is not practiced. Gloves should be worn when taking radiographs and handling contaminated film packets. Other PPE should be used if spattering of blood or other body fluids is likely. Care should be taken to avoid contamination of the developing equipment by barriers or be cleaned and then disinfected after each patient use with an EPA-registered hospital disinfectant with of low or intermediate-level activity. Digital radiography instruments should be cleaned and ideally heat-sterilized or high-level disinfected between patients. Consult manufacturers regarding appropriate barrier and sterilization procedures for digital radiography sensors and computer components.
Extracted teeth that are being discarded are subject to the containerization provisions outlined by OSHA‘s bloodborne pathogens standard. OSHA considers extracted teeth to be potentially infectious material that should be disposed in medical waste containers. However, extracted teeth can be returned to patients on request, at which time provisions of the standard no longer apply.
Review and follow the Management Plan, Infection Prevention Practices and other content as applicable in the OSDH Infection Prevention and Control Manual.
Additional dental infection control information can be obtained from:
1. Guidelines for Infection Control in Dental Health-Care Settings 2003
MMWR – December 19, 2003/Vo. 52/No. RR-17
2. Organization for Safety and Asepsis Procedures (OSAP)
3. From Policy to Practice: OSAP‘s Guide to the Guidelines. OSAP,
Annapolis, 2004
4. Material Safety Data Sheets (MSDS)
Emergency Medical Equipment
1. Resuscitator Bags- Disposable resuscitator bags are recommended, and should be disposed of promptly after use. If non-disposable resuscitator equipment is used, resuscitator bags (i.e., adult and pediatric ambu bags) and pocket resuscitator masks must be cleaned following the manufacturer‘s instructions for cold sterilization.
2. Airways, Oxygen, Masks, and Tubing- All disposable equipment should be disposed of after use. Proper disposal of this equipment is covered in Section 5.
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3. Mannequins- Students should be told in advance that cardiopulmonary resuscitation (CPR) training sessions will involve ―close physical contact‖ with their fellow students.
Students should not actively participate in training sessions (hands-on training with mannequins) if they have dermatologic lesions on hands or in oral or circumoral areas, if they are known to be seropositive for hepatitis B surface antigen (HbsAg), if they have an upper respiratory tract infection, if they are known to be seropositive for Human Immunodefiency Virus (HIV), or if the student has reason to believe that he or she has been exposed to or is in the active stage of any infectious process.
All persons responsible for CPR training should be thoroughly familiar with hygienic concepts (i.e. thorough handwashing prior to mannequin contact, not eating during class to avoid contamination of mannequins with food particles, etc.) as well as the procedures for cleaning and maintaining mannequins and accessories (i.e., face shield). Mannequins should be inspected routinely for signs of physical deterioration, such as cracks or tears in plastic surfaces, which make thorough cleaning difficult or impossible. The clothes and hair of the mannequins should be washed periodically (i.e., monthly or whenever visibly soiled).
If more than one CPR mannequin is used in a particular training class, students should preferably be assigned contact with only one mannequin. Each student should use a disposable face shield specifically designed for use with mannequins. Following this recommendation will lessen the possible contamination of several mannequins by one individual and, therefore, limit possible exposure of other class members.
At the end of each class, the procedures listed below should be followed as soon as possible to avoid drying of contamination on mannequin surfaces:
a. Disassemble mannequin as directed by manufacturer.
b. As indicated, thoroughly wash all external and internal surfaces (also reusable protective face shields) with warm water, detergent and brushes.
c. Rinse all surfaces with fresh water.
d. Wet all surfaces with a 1:10 bleach dilution. This solution must be made fresh at each class and discarded after use.
e. Rinse with fresh water and immediately dry all external and internal surfaces; rinsing with alcohol will aid drying of internal surfaces, and this drying will prevent the survival and growth of bacterial or fungal pathogens.
Each time a different student uses the mannequin in a training class, the individual protective face shield, if used, should be changed. Between students or after the instructor demonstrates a procedure, the mannequin face and inside the mouth should be wiped vigorously with clean absorbent material (i.e., 4‘x4‖ gauze pad) wet with either the bleach solution described above or with 70% alcohol (isopropanol or ethanol). The surfaces should remain wet for at least 30 seconds before they are wiped dry with a second piece of clean absorbent material. Although alcohol is not a broad-spectrum bacteriological agent, in the context of vigorous cleaning with alcohol and absorbent material, little viable microbial contamination is likely after the cleaning procedure. 2011 Infection Prevention and Control Manual 42
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Management of Regulated Medical Waste
Regulated Medical Waste Disposal Plan
he following information shall serve as the Oklahoma State Department of Health Regulated Medical Waste Disposal Policy and Plan as required by the Oklahoma Department of Labor Public Employees Occupational Safety and Health Division. The Oklahoma State Department of Health will follow all applicable standards as written from the:
Oklahoma State Department of Labor Public Employees Occupational Safety and Health Division OS Title 40
Occupational Safety and Health Administration Standard 1910.1030 (d)
United States Department of Transportation Title 49 CFR 173.196-197; and, Oklahoma Department of Environmental Quality 27A 252:515-23 for the containment, transporting and disposal of all regulated medical waste.
Definitions
“Commercial regulated medical waste processing facility” means a facility operated as a business for profit that is designed and operated principally for the purpose of processing, including transfer of, regulated medical wastes generated by others. Such facilities shall include those engaged in the processing of regulated medical waste on mobile vehicles at a generator location. (DEQ 252:515-23-2)
“Commercial transporter “means an owner/operator of any vehicle transporting regulated medical waste generated by others. (DEQ 252:515-23-2)
“Contaminated Sharps” means any contaminated object that can penetrate the skin including, but not limited to, scalpels, broken glass, broken capillary tubes, and exposed ends of dental wires. (OSHA 1910.1030(b)
“DEQ” means the Oklahoma Department of Environmental Quality.
Section
5
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“Engineering Controls” means controls (i.e., sharps disposal containers, self sheathing needles, safer medical devices, such as sharps with engineered sharps injury protections and needleless systems) that isolate or remove the bloodborne pathogens hazard from the workplace. (OSHA 1910.1030(b)
“Generator” means the owner/operator of any facility, institution, or business that produces regulated medical waste in any quantity. (DEQ 252:515-23-2)
"MSWLF" means Municipal Solid Waste Landfill; a publicly or privately owned landfill that is/or has received household waste. A MSWLF may also receive other types of non-hazardous solid wastes, such as non-hazardous sludge, NHIW, special waste, and construction/demolition waste.
“OSHA” means Occupational Safety and Health Administration.
"POTW" means Publicly Owned Treatment Works; a wastewater treatment system, as defined at 27A O.S. § 2-6-101, that is owned by a State or municipality for the treatment of municipal or industrial wastewaters.
“Regulated medical waste” means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials. (OSHA 1910.1030(b)
“DOT” means United State Department of Transportation
Examples of Regulated Medical Waste Within a County Health Department Live and attenuated vaccines that are being discarded. Blood and blood products-Discarded waste, human blood and blood products (i.e. serum, plasma) and materials as defined above as regulated medical waste. Sharps-Used sharps such as hypodermic needles, syringes, blood collection tubes, broken or unbroken glassware in contact with infectious items, including slides and cover slips. Items contaminated with blood or other human body fluids, which would drip freely or would release such materials if compressed. Items caked with dried blood or body fluids that are capable of releasing these materials, such as filter paper. Discarded feminine hygiene products used to absorb menstrual flow does not meet the definition of regulated waste. These items should be discarded in the regular waste receptacles that have been properly lined with a plastic bag. 2011 Infection Prevention and Control Manual 45
Discarded waste material contaminated with excretions, exudates, and secretions from clients with highly communicable diseases. Material, which, in the determination of the communicable disease nurse presents a significant danger of infection because it is contaminated with infectious agents.
Disposal of Regulated Medical Waste
Immediately, or as soon as possible after use, contaminated medical waste shall be placed in appropriate containers as follows:
1. Sharps- Must be placed in puncture-resistant, rigid containers immediately after use. Containers must be red in color, labeled with the universal biohazard symbol and closable. Containers must be located as close as possible to the use area, preferably within arm‘s reach of the user. Containers must not be placed on the floor, or in an area that is within the reach of small children. Containers must be considered full when between 1/2 to 2/3 filled and must be securely closed and stored for final disposal at that time. Under no circumstance should needles or lancets be recapped or otherwise manipulated by hand and must not require transport to another room for disposal in a sharps container.
2. Regulated medical waste other than sharps- must be placed in a fluid-resistant, closable container or bag colored red and/or labeled with the universal biohazard symbol. Plastic bags should be constructed of either polyethylene or polypropylene and should be impervious and tear resistant. These bags should be capable of being closed off, tied or sealed.
3. The disposal of the following is prohibited in a municipal solid waste landfill, a municipal solid waste receptacle or a municipal solid waste transfer station- any quantity of regulated medical waste as defined above under the OSHA 1910.1030(b) (definitions above) ―Regulated Medical Waste‖.
4. Liquid regulated medical wastes-may not be discharged into the collection system of a Publicly Owned Treatment Work (sewer) within the generating facility.
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Storage of Regulated Medical Waste in a County Health Department Prior to Final Disposal
Bagged regulated waste must be kept in secondary fluid-resistant, rigid containers (such as garbage cans or corrugated boxes) with closable tops while in the clinic setting. Reusable containers must be disinfected on a regularly scheduled basis and when visibly contaminated.
Sharps containers do not require a secondary container unless observed to be leaking or unless the integrity of the container has been compromised (indented, cracked, etc.).
At the end of each day or completion of clinic, regulated medical waste bags must be removed from secondary fluid-resistant container by appropriate health department personnel with annual bloodborne pathogen training and placed in box provided by the state contracted commercial transporter. These bags must be securely closed, placed in a box and locked in a storage room, which has limited access, this room must be labeled as biohazard. Contracted cleaning personnel are not to handle regulated medical waste and are to be made aware of the process and hazard.
Care must be taken to ensure that storage rooms are free of rodents and other disease vectors and are protected against precipitation.
Stored regulated medical waste must be maintained in a non-putrescent state, using refrigeration if necessary.
Options for Final Disposal of Regulated Medical Waste
OSDH must contract with a commercial regulated medical waste transportation and disposal company approved for operation by the Oklahoma Department of Environmental Quality- A contract for regulated medical waste transportation and disposal is available to county health departments. The company under contract provides containers for packaging and collection of full containers. An approved regulated medical waste tracking form must be received from the contracted commercial transporter every time waste is tr